ACA StandardHealth with Health Choice Dental Prior Authorization Codes List
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This document lists dental procedure CDT codes and brief descriptions used for prior authorization under the payer's ACA StandardHealth with Health Choice Dental plan; it affects providers submitting dental prior authorization requests to the payer.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Prior authorization code list
Codes included for use in prior authorization processing; individual coverage determinations are governed by separate policy documents.
ALL of the following
Prior authorization codes
- D2740 — Crown: porcelain/ceramic substrate
- D2750 — Crown: porcelain fused to high noble metal
- D2751 — Crown: porcelain fused to predominantly base metal
- D2752 — Crown: porcelain fused to noble metal
- D2790 — Crown: full cast high noble metal
- D2791 — Crown: full cast predominantly base metal
- D2792 — Crown: full cast noble metal
- D4286 — Removal of non-resorbable barrier
- D7280 — Surgical access of an unerupted tooth
- D7282 — Mobilization of erupted or malpositioned tooth to aid eruption
- D7961 — Buccal/labial frenectomy (frenulectomy)
- D7962 — Lingual frenectomy (frenulectomy)
Dental CDT Codes
| D2740 | Crown - porcelain/ceramic substrate |
| D2750 | Crown - porcelain fused to high noble metal |
| D2751 | Crown - porcelain fused to predominantly base metal |
| D2752 | Crown - porcelain fused to noble metal |
| D2790 | Crown - full cast high noble metal |
| D2791 | Crown - full cast predominantly base metal |
| D2792 | Crown - full cast noble metal |
| D4286 | Removal of non-resorbable barrier |
| D7280 | Surgical access of an unerupted tooth |
| D7282 | Mobilization of erupted or malpositioned tooth to aid eruption |
Provider Actions and Prior Authorization Requirements
Prior authorization codes (ACA StandardHealth with Health Choice Dental)
Submit prior authorization requests to Blue Cross Blue Shield of Arizona for the following dental procedures under the ACA StandardHealth with Health Choice Dental plan. Use the listed CDT code and description exactly as shown when requesting authorization.
- D2740 — Crown - porcelain/ceramic substrate
- D2750 — Crown - porcelain fused to high noble metal
- D2751 — Crown - porcelain fused to predominantly base metal
- D2752 — Crown - porcelain fused to noble metal
- D2790 — Crown - full cast high noble metal
- D2791 — Crown - full cast predominantly base metal
- D2792 — Crown - full cast noble metal
- D4286 — Removal of non-resorbable barrier
- D7280 — Surgical access of an unerupted tooth
- D7282 — Mobilization of erupted or malpositioned tooth to aid eruption
- D7961 — Buccal/labial frenectomy (frenulectomy)
- D7962 — Lingual frenectomy (frenulectomy)
Code Descriptions
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