Evaluation codes may require written medical justification

Evaluation codes D0120, D0140 and D0145 are shown in the fee schedule with “Service Authorization / Written Medical Justification Required” and require tooth/surface reporting as indicated on the fee line; attach written medical justification to the claim when the billing note indicates this requirement.

• Codes: D0120, D0140, D0145
• Action: Attach written medical justification to claim when fee-line billing note requires it
• Reporting: Tooth Code and Surface Code required where indicated

Radiograph/panoramic codes require written justification when flagged

Radiograph and panoramic imaging codes (examples: D0240, D0270–D0277, D0330) are flagged with Service Authorization/Written Medical Justification or listed ‘By Report’ — providers must attach written medical justification to the claim when the fee line indicates “Attach written medical justification to claim” or the code is marked By Report.

• Examples: D0240, D0270, D0272, D0273, D0274, D0277, D0330
• Action: Attach written medical justification to claim when billing note indicates (X/By Report/Attach written medical justification to claim)

Attach written medical justification for lab/diagnostic tests when indicated

Laboratory and diagnostic procedures (examples: D0417, D0460, D0470, D0475, D0482, D0483) are marked X/By Report and require that providers attach written medical justification to the claim for reimbursement when the billing note indicates “Attach written medical justification to claim.”

• Examples: D0417 (collection of saliva), D0460 (pulp vitality tests), D0470 (diagnostic casts), D0475 (decalcification), D0482/D0483 (immunofluorescence)
• Action: Attach written medical justification to claim when fee-line billing note shows X or By Report

Attach written justification to claim for listed pediatric services when billing note requires it

For a set of pediatric procedure codes listed in the schedule, providers must attach written medical justification to the claim when the billing notes state “Attach written medical justification to claim”; for certain high-volume crown situations, prior authorization is required (see crown thresholds).

• Action: Attach written medical justification to claim for codes whose billing note indicates this requirement
• Examples include multiple prophylaxis, diagnostic, and sealant/space-maintainer entries shown with attach/ X/By Report notes

Service authorization or documentation required for multiple listed codes

Several listed codes (examples include preventive, diagnostic casts, immunofluorescence and certain restorative entries) require either service authorization with written medical justification or that a written medical justification be attached to the claim when the fee line indicates that billing note.

• Examples: D1206, D1208, D1351, D1510, D0470, D0475, D0482, D0483, D1110, D1120, D1556–D1558
• Action: Obtain service authorization or attach written medical justification to the claim as directed by the fee-line billing note

Examples of CDT codes marked for written justification

Specific CDT codes (examples shown in the schedule such as D1556, D1557, D1558, D1110, D1120, D1206, D1208, D1351, D1510 and others) are identified with “Service Authorization Written Medical Justification Required” — providers must follow the fee-line note and attach a written medical justification to the claim when indicated.

• Codes listed with this requirement include D1556, D1557, D1558, D1110, D1120, D1206, D1208, D1351, D1510, D1516, D1517
• Action: Attach written medical justification to claim when fee-line shows the requirement

Attach written justification for pediatric services; prior auth for multiple crowns

Multiple pediatric services (including many crown codes and related procedures) require that providers attach written medical justification to the claim when 1–2 crowns are placed on a date of service; if 3 crowns on a single date or 4 or more crowns within 12 months are proposed, prior authorization must be obtained for consideration.

• Attach written medical justification when billing 1–2 crowns on same date unless prior authorization is submitted on the claim
• Obtain prior authorization for 3 crowns on a date of service or 4+ crowns in a 12-month period

Attach written justification or obtain prior authorization per crown thresholds

Providers must attach written medical justification to the claim for several pediatric services (examples repeated across crown and restorative entries); when a billing line shows this instruction, include the justification with the claim or submit prior authorization as permitted.

• Action: Attach written medical justification to claim when indicated (fee-line example shown)
• Prior authorization required for 3 crowns on date of service or 4+ crowns in 12 months

Attach written medical justification to claim where fee line specifies

Any fee-schedule entry that includes the billing note “Attach written medical justification to claim” requires providers to include that narrative justification with the claim — follow the exact fee-line instruction for each listed procedure.

• Action: For codes with the billing note “Attach written medical justification to claim,” include the justification on the claim submission
• Examples: many restorative and crown codes in the pediatric section

D2390 and specified procedures require written justification and prior auth rules

Anterior resin-based composite crown (D2390) and other listed crown/composite codes are marked “Service Authorization Written Medical Justification Required” — attach written medical justification to the claim when billing these codes and follow prior authorization thresholds for multiple crowns.

• Code example: D2390 (resin-based composite crown, anterior)
• Action: Attach written medical justification to claim when billing; obtain prior authorization for multiple crowns per thresholds

Posterior composite codes require written justification and follow crown PA thresholds

Posterior resin-based composite procedures (D2391, D2392) and related posterior composite codes include Service Authorization/Written Medical Justification flags — attach written medical justification to the claim when the billing note indicates it and obtain prior authorization for multiple crowns as required.

• Codes: D2391, D2392 (posterior composite examples)
• Action: Attach written medical justification to claim when fee-line indicates; prior auth required for thresholds of multiple crowns

Crown documentation: attach justification for 1–2 crowns; prior auth for 3+/4+

For crowns generally: if 1–2 crowns are provided on the same date of service, attach written medical justification to the claim unless prior authorization is submitted on the claim; if 3 crowns on a date of service or 4 or more crowns within 12 months are planned, providers must obtain prior authorization for consideration.

• 1–2 crowns on date of service: attach written medical justification to claim unless prior authorization is on the claim
• 3 crowns on date of service or 4+ crowns in 12 months: prior authorization required for consideration

Service authorization flags require tooth/surface reporting and justification

Many restorative and crown codes are marked with Service Authorization/Written Medical Justification (‘X’) and require tooth and surface codes to be reported on the claim — follow the fee-line X flags and include tooth/surface reporting where required.

• Action: Include Tooth Code and Surface Code on claim where fee-line indicates
• Action: Attach written medical justification when X or attach-note appears

Written justification vs prior authorization for crowns

When 1–2 crowns are billed on the same date of service and no prior authorization is submitted, providers must attach a written medical justification to the claim; for 3 crowns on a date of service or 4+ crowns in 12 months, prior authorization is required for consideration.

• Action: Attach written medical justification for 1–2 crowns unless prior authorization is on the claim
• Action: Obtain prior authorization for 3 crowns on a date or 4+ crowns in 12 months

Authorization may be submitted on the claim for some codes

Some fee lines indicate “authorization submitted on claim” or similar — providers may indicate prior authorization on the claim itself to avoid a separate prior authorization submission; if that option is used, do not also attach written justification unless the fee-line requires it when no prior authorization is present.

• Action: Use the claim’s authorization field when fee-line indicates “authorization submitted on claim”
• Note: If prior authorization is submitted on claim, written medical justification attachment is not required per the fee-line

Crown and restorative codes: attach justification or obtain prior auth per thresholds

For specified crowns and selected restorative codes (examples listed across the crown sections), attach written medical justification to the claim when 1–2 crowns are provided on the date of service; obtain prior authorization for 3 crowns on a date of service or 4+ crowns in 12 months for consideration. If prior authorization is submitted on the claim, written justification is not required.

• Action: Attach written medical justification for 1–2 crowns if no prior authorization
• Action: Prior authorization required for 3 crowns/date or 4+ crowns/12 months

Prior authorization required for multiple pediatric crowns

Prior authorization is required for consideration when 3 crowns are placed on a single date of service or when 4 or more crowns are placed within a 12-month period; when only 1–2 crowns are placed and no prior authorization is submitted, attach written medical justification to the claim.

• Threshold: 3 crowns on same date OR 4+ crowns within 12 months → prior authorization required
• If 1–2 crowns on date and no prior auth: attach written medical justification to claim

Attach written justification for crowns when fee-line indicates; prior auth for thresholds

Crown billing lines instruct providers to attach written medical justification to the claim for 1–2 crowns when no prior authorization is present; for multiple crowns above the thresholds, prior authorization must be obtained for consideration.

• Action: Attach written medical justification for 1–2 crowns unless prior authorization is included on the claim
• Action: Obtain prior authorization for 3 crowns/date or 4+ crowns/12 months

Same attach/PA rules apply to additional crown codes

Additional crown codes (including porcelain-fused and other materials) carry the same documentation/prior authorization rule: attach written medical justification for 1–2 crowns if no prior authorization; obtain prior authorization for 3 crowns on a date of service or 4+ crowns in 12 months.

• Applies to codes such as D2752, D2791, D2794 and related crown entries
• Action: Follow attach/PA thresholds as shown on fee lines

Provisional/recement crowns: attach justification or obtain prior auth as required

Provisional and recement crown entries (examples: D2799, D2915, D2920, D2928) instruct providers to attach written medical justification to the claim for 1–2 crowns when no prior authorization is submitted; prior authorization is required for 3 crowns on a date or 4+ crowns in 12 months.

• Examples: D2799 (provisional crown), D2915/D2920 (recement)
• Action: Attach written medical justification for 1–2 crowns if no prior auth; obtain prior authorization for higher thresholds

Pediatric crown rules: attach justification for 1–2 crowns; PA for 3+/4+

The pediatric crown section repeatedly instructs providers to attach written medical justification to the claim for 1–2 crowns when prior authorization is not submitted; if 3 crowns on a date or 4+ crowns in 12 months are proposed, prior authorization must be obtained for consideration.

• Action: Attach written justification for 1–2 crowns without prior authorization
• Action: Obtain prior authorization for 3 crowns/date or 4+ crowns/12 months

Authorization can be indicated on fee lines (authorization submitted on claim)

Several fee lines indicate that authorization can be submitted on the claim itself for certain prefabricated crown codes and others — where the fee line shows “authorization submitted on claim,” providers may indicate authorization on the claim to satisfy the requirement instead of a separate submission.

• Action: Submit authorization on the claim when the fee line indicates “authorization submitted on claim”
• Note: If prior authorization is on the claim, attaching written medical justification is not required per the fee line

Prefabricated crown claims: attach justification or obtain prior auth per thresholds

Prefabricated crowns (codes D2929–D2932 and related entries) require providers to attach written medical justification to the claim when 1–2 crowns are provided and no prior authorization is submitted; prior authorization is required for 3 crowns on a date or 4+ crowns in 12 months.

• Codes: D2929, D2930, D2931, D2932 (prefabricated crowns)
• Action: Attach written justification for 1–2 crowns unless prior authorization is submitted; obtain prior authorization for thresholds

Attach justification for crowns and associated restoratives; prior auth required at thresholds

For crowns and associated restorative procedures listed (examples include D2930–D2975 series and related codes), the fee schedule requires attaching written medical justification to the claim when 1–2 crowns are provided without prior authorization and requires prior authorization for 3 crowns on a date or 4+ crowns in 12 months; if prior authorization is submitted on the claim, the written justification is not required.

• Action: Attach written medical justification for 1–2 crowns when no prior authorization
• Action: Obtain prior authorization for 3 crowns/date or 4+ crowns/12 months; prior authorization indicated on claim fulfills requirement