Predetermination requirement

If the expected charge for treatment exceeds $300, a predetermination (pre-treatment estimate) is strongly advised before initiating services. Dominion may request diagnostic materials (recent radiographs, periodontal charting, photographs, and other dental records) to issue a predetermination. A predetermination documents proposed services and specified coverage but is not a guarantee of payment and is valid for 180 days.

• Predetermination recommended when expected charges > $300
• Predetermination may require radiographs, periodontal charting, or other dental records
• Predetermination is valid for 180 days and not a guarantee of payment

Endodontic billing and documentation rules

Certain endodontic services and related items are considered integral to root canal therapy and may not be billed separately when performed on the same tooth on the same date of service. Submit post-operative periapical radiographs when post/core or crown is placed following root canal therapy.

• Do not separately bill D0220/D0230 working films, D0460, D2940, D3120, D3220, D3221, D3910, D3950, D9110 when performed with root canal therapy on same tooth/date
• Post-operative periapical x-ray required when core build-up, post and core, and/or crown are placed after root canal

Periodontal procedure documentation

Periodontal surgical and non‑surgical procedures require specific documentation and clinical qualifying criteria. Provide recent radiographs, current periodontal charting, and intraoral photos where indicated. Some procedures (e.g., gingivectomy, osseous surgery, crown lengthening) have explicit pocket depth, attachment loss, and radiographic bone‑loss requirements.

• For gingivectomy (D4212): photo, radiograph, and periodontal charting required; allowed when performed to facilitate a restorative procedure
• Gingival flap/root planing (D4240/D4241): pockets > 4 mm with loss of attachment required to qualify
• Scaling and root planing (D4341/D4342): periodontal probings > 4 mm and radiographic bone loss required; limit of two full quadrants per date of service
• D4381 (localized antimicrobial delivery) is per‑tooth and requires a 30‑day healing period after D4341/D4342
• Osseous surgery and apically positioned flap procedures require film of treatment area and current periodontal charting

Verify eligibility / Pre-treatment estimate recommended

Verify member eligibility before creating a treatment plan and obtain a pre‑treatment estimate for complex/prosthetic services (including removable prosthodontics and implant services). Pre-treatment radiographs and extraction dates are commonly requested to determine benefits.

• Strongly recommended to verify eligibility for D5000–D5899 and D6000–D6199 services
• Obtain pre‑treatment estimate for removable prosthodontics and implant services
• Provide recent full‑arch/pre‑operative radiographs and dates of extractions when requested

Denial risks include submission of radiographs that are inadequate

Claims may be denied if submitted radiographs are not diagnostic quality, are the incorrect type for the procedure, lack proper labeling (R/L), or are missing required views. If a pre‑operative radiograph does not support the billed code, include a narrative explanation.

• All radiographs must be diagnostic quality, labeled, and the correct type for the procedure (periapical for crowns/bridges; bitewings not acceptable for crown/bridge)
• Radiographs must include apex when periapical films are required and indicate right (R) or left (L)
• If radiograph does not support use of the code, include a narrative with clinical justification

Benefits will not be provided when the restorability or disease status is inadequate

Benefits will not be provided when the tooth has a poor prognosis or there is untreated periodontal disease, unresolved periapical pathology, failed endodontic therapy, or when a more conservative restoration would suffice. Documentation must support clinical necessity.

• Not covered when a more conservative restoration is adequate or treatment is cosmetic for stress fractures/craze lines without symptoms
• Not covered with untreated bone loss, untreated periodontal disease, or poor restorative/endodontic/periodontal prognosis
• Crown/core/post benefits denied if unresolved periapical pathology or failed endodontic therapy exists

Benefits will be denied if the abutment tooth has poor prognosis

Benefits will be denied for partial dentures if the abutment tooth has a poor restorative, periodontal, or endodontic prognosis. Confirm abutment tooth viability and provide supporting documentation (radiographs, treatment notes).

• Evaluate abutment tooth prognosis before approving partial denture benefits
• Provide recent pre‑treatment full‑arch radiographs and date(s) of extraction as requested for partial denture cases

Denial triggers

Common denial triggers include failure to submit a primary carrier's Explanation of Payment (EOP) when Dominion is secondary, missing pre‑operative radiographs, inadequate narratives when radiographs are nondiagnostic, and lacking requested supporting records (periodontal charting, photos, surgical plans).

• Submit primary carrier EOP for wisdom tooth (third molar) extractions when Dominion is secondary
• Include pre‑operative radiograph for surgical procedures; add a narrative if x‑ray does not justify the code
• Provide intraoral photos, panoramic/cephalometric radiographs, and a surgical treatment plan for specified services

Narrative requirement

For many procedures the carrier requires a narrative describing the clinical indication and justification for treatment when the radiograph or standard documentation does not fully support the code. Include operative notes, symptom history, dates of onset, and conservative treatment attempts where relevant.

• Narrative required when radiographs are nondiagnostic or do not support billed code
• For cracked tooth syndrome and other conditions provide dates of symptom onset, reassessments, and prior conservative treatment attempts
• Include operative notes and clinical findings to support medical necessity

Provide a pre-operative periapical diagnostic radiograph when required

Provide a recent pre‑operative periapical radiograph (or panoramic when specified) for crown, crown‑type, implant, and certain periodontal procedures. Periapical films must include the apex and be of diagnostic quality. Bitewings are not acceptable for crown/bridge procedures.

• Recent pre‑treatment periapical x‑ray required for most crown codes (document specific tooth)
• Provide full‑arch pre‑implant radiographs and periapical films pre‑ and post‑implant as requested
• Ensure radiographs include tooth‑level identification and apex

Tooth-level documentation and recent pre/post-treatment radiographs required

To support tooth‑level procedures (crowns, abutments, implant components, localized periodontal treatments), include tooth‑specific documentation: recent periapical radiographs, tooth number, date(s) of extractions if relevant, periodontal charting, and narrative when indicated.

• Submit tooth number with recent pre‑ and/or post‑treatment periapical radiographs for implant abutments and crowns (e.g., D6056–D6058, D6104, D6193)
• Provide date(s) of extraction and full‑arch radiographs for prosthodontic (removable/fixed) documentation
• Localized procedures (D4381) require tooth‑level periodontal charting and radiographs

For periodontal procedures provide 6‑point charting and radiographs

For periodontal procedures provide a comprehensive 6‑point periodontal charting and recent radiographs (full‑arch or focused films) of the treatment area. Clinical criteria (probing depths, attachment loss, and radiographic bone loss) must be documented to justify scaling/root planing, osseous surgery, and maintenance.

• 6‑point periodontal charting and current radiographs required for osseous surgery and apically positioned flap procedures
• Scaling/root planing requires documentation of periodontal probings > 4 mm and radiographic bone loss
• Periodontal maintenance (D4910) requires history of periodontal surgery within previous 24 months

For gingivectomy to qualify as restorative, submit photo/radiograph/charting

A gingivectomy (D4212) will be considered a restorative adjunct when performed to facilitate a restoration (e.g., to expose crown margins). To qualify as restorative, provide a photo, radiograph, and periodontal charting documenting the indication.

• Gingivectomy must be documented as necessary to enable restorative treatment (fractured tooth structure or decay at/below gum line, or gingival overgrowth)
• Required documentation: photo, radiograph, and periodontal charting

Required radiographs and extraction dates for implants

For implant services submit full‑arch pre‑implant radiographs and radiographs taken at implant placement to determine restorative/prosthetic benefits. For specific implant‑related CDT codes include recent pre‑ and post‑treatment periapical radiographs and tooth identification; some implant procedures also require a narrative.

• Full‑arch pre‑implant placement radiographs and radiographs of implant placement are required to evaluate benefits
• For D6056–D6058, D6104, D6180, D6193 and similar codes include recent periapical radiographs and tooth‑level documentation
• Replacement of an implant screw (D6193) requires a narrative

Code-specific documentation for implants and prosthetics

Certain implant and prosthetic CDT codes have explicit documentation expectations: provide recent pre‑ and post‑treatment periapical radiographs, tooth identification, dates of extraction, and narratives where noted. Failure to supply code‑specific records may delay or deny benefit determination.

• D6049, D6056–D6058, D6104, D6180, D6193: require recent pre‑ and/or post‑treatment periapical radiographs and tooth number
• Provide dates of extraction and full‑arch radiographs for pontics and removable prosthodontics (D6205, D6211, D6212, etc.)
• Pre‑determination for implant+abutment+crown approvals depends on implant placement documentation and submitted films

D4381 (localized antimicrobial delivery)

Localized antimicrobial delivery (D4381) is considered a per‑tooth procedure and requires supporting periodontal charting and a recent full‑arch or focused radiograph of the treatment area. Benefits for D4381 require a 30‑day healing period after scaling/root planing (D4341/D4342).

• D4381 billed per tooth only
• Must document periodontal charting and recent radiograph of the treatment area
• 30‑day healing period required after D4341 or D4342 before D4381 will be allowed