BCBS-RI Dental Procedures Coverage Update

Coverage Criteria

inv-01: Additional procedures to construct new crown under existing partial denture framework - Frequency

Coverage for D2971 is limited by frequency

D2971 frequency criteria: D2971 is covered only as allowed by frequency: 1 per 5 years.1 per 5 years

Additional procedures within the 5 years are not covered and are member liability.

inv-02: Adjustments to Dentures

Adjustments to dentures policy

Denture adjustment timing: Adjustments to complete or partial dentures performed within six months of delivery are considered part of initial placement and not billable; after six months benefits are limited to one adjustment in a 12‑month period.1 per 12 months

Additional adjustments are not covered and are member liability.

inv-03: Alveoloplasty

Alveoloplasty coverage limits and relationships

Alveoloplasty frequency: Alveoloplasty procedures are limited to once per quadrant in a five‑year period.Once per quadrant per 5 years

D7311 performed in conjunction with extractions on the same date by the same dentist is considered integral to the extraction and may not be billed separately to the member.

inv-04: Amalgams and Composites

Restorative procedures coverage and replacement timing

Restoration inclusion: Placement of amalgam or composite restorations includes liners, base, pulp cap, bonding adhesive, polishing and local anesthesia as part of the restorative procedure.

Effective 01/01/2023, composite restorations are covered on all teeth.

Replacement frequency: Replacement of an existing amalgam or composite restoration is payable only after 12 months have passed since the previous placement; replacement within 12 months by the same participating dentist/office is considered integral to the initial placement and may not be billed to the member.12 months

inv-05: Anatomical Crown Exposure - Not Covered

Not covered (member liability) when billed as listed CDT codes.

Anatomical crown exposure not covered: D4230 and D4231 (anatomical crown exposure) are not covered and are member liability.

Procedure involves removal of enlarged gingival tissue and ostectomy to provide anatomically correct gingival relationship.

inv-06: Anesthesia Coverage Criteria

Coverage depends on anesthesia type and relationship to other procedures.

Local/regional anesthesia integral: Local anesthesia (D9210, D9215) and regional/trigeminal block anesthesia (D9211, D9212) are considered integral to the greater procedure and a participating dentist may not bill the member separately.

Evaluation for deep sedation (D9219) is also integral to anesthesia administration.

General anesthesia/IV sedation covered with qualifying procedures: General anesthesia and IV sedation (D9222–D9225; selected D9246–D9247) are covered only when performed in conjunction with specified oral surgery/procedure codes and are subject to individual Dental Consultant review.

D9220/D9221 limited to 60 minutes; charges exceeding 60 minutes are not covered unless individual consideration is granted.

Not covered anesthesia services: Administration of nitrous oxide (D9230) and certain enteral/moderate sedation codes (D9244, D9245) are not covered and are considered member liability.

inv-07: Apexification/Recalcification Criteria

Coverage and limitations for apexification/recalcification and pulpal regeneration

Apexification/recalcification review: Apexification/recalcification procedures (D3351–D3353) do not require review.

These procedures require intra‑canal medication and appropriate radiographs.

Age limitation: Apexification/recalcification is not covered on primary teeth and is not covered on permanent teeth of members over age 15.

Pulpal regeneration frequency: Pulpal regeneration codes (D3355–D3357) are covered once per tooth per lifetime.once per tooth per lifetime

Root canal treatment will be offset by the amount benefitted for pulpal regeneration if performed within 12 months prior.

inv-08: Apically Positioned Flap - Coverage

Apically positioned flap coverage stance

Apically positioned flap integral: D4245 (apically positioned flap) is considered integral to the greater procedure and a participating dentist may not bill the member separately.

Used to preserve keratinized gingiva in conjunction with osseous resection, second‑stage implant procedures, exposure of impacted teeth, or peri‑implantitis treatment.

inv-09: Core Buildup - Indications

Coverage criteria for core build-up

Core build-up indication: A core build‑up (D2950) is indicated when replacement of missing tooth structure is required to obtain adequate resistance and retention for crown placement; Dentist Advisor review may be required for large restorations with limited remaining tooth structure.

Pre‑operative periapical x‑ray and photos (if available) are required for documentation; not covered for members under age 14 unless clinical rationale provided.

inv-10: Complete Dentures - Coverage and Frequency

Coverage stance for complete dentures

Complete dentures coverage: Complete denture benefits include adjustments, reline/rebase or repairs for six months following delivery; insertion date is the completion date for benefit payment. Complete dentures are payable once per arch in a five‑year period.once per arch per 5 years

Specialized procedures are non‑covered and the patient is responsible for payment with documented consent.

inv-11: Periradicular Surgery - Definition and Exclusions

Periradicular surgery coverage notes

Periradicular surgery definition: Periradicular surgery (apicoectomy and related procedures D3410–D3427) covers surgical treatment at the root apex or along the root surface; this definition does not include placement of retrograde filling material.

Guided tissue regeneration (D3432) when performed in conjunction with periradicular surgery is not covered and is considered member liability.

inv-12: Eligibility for crown/crown lengthening coverage

Covered when ALL of the following are met for crowns and crown lengthening:

crown_lengthening_purpose: Crown lengthening (clinical crown lengthening-hard tissue) is performed to allow access to sound tooth structure for restoration or crown placement and requires reflection of a flap and bone removal in a healthy periodontal environment.

Pre‑operative periapical x‑ray required; benefit once per tooth per lifetime; additional procedures on same tooth not covered.

periodontal_environment: Crown coverage eligibility requires a healthy periodontal environment distinct from osseous surgery for periodontal disease.

Tooth must have sound endodontic and periodontal prognosis for crown eligibility.

tooth_prognosis_for_crown: A tooth must have adequate periodontal and endodontic prognosis and meet restorative criteria to be eligible for crown coverage.

Crowns are generally not covered for members under age 14 unless clinical rationale provided; radiographic evidence of poor prognosis or inadequate bone support may result in denial.

inv-13: Crown repair criteria

Crown repair coverage is conditional:

repair_review: Crown repair (D2980–D2982) allowance is determined by consideration of time, difficulty and materials used; Dentist Advisor review may be required and adequate clinical documentation should be submitted.

Documentation: x‑rays, treatment notes, narrative, photos and lab charges if applicable.

repair_allowance_factors: Repairs are considered integral if performed within 12 months of insertion by the same dentist; thereafter repairs are limited to once in 36 months.12 months then 36 months

Additional repairs outside allowed frequency are member liability.

repair_timing: When repair is within 12 months by same dentist it is integral to the crown; after 12 months, benefit limited to once in 36 months.

inv-14: Crown Coverage Criteria

Covered when ALL of the following are met

Crown coverage general criteria: Crowns are covered when specific restorative criteria are met (e.g., large existing restorations involving ≥50% of tooth structure, cuspal/incisal fracture ≥50% of incisal angle, extensive recurrent decay, posterior teeth with restorations of ≥3 surfaces leaving thin walls, or anterior teeth with ≥2 surfaces or proximity to the pulp).at least 50% involvement for key criteria

Study models and temporary crowns are integral; recementation within 12 months is integral and not separately billable.

Exclusionary conditions for crowns: A crown may be denied if for cosmetic reasons (including peg lateral), to increase vertical dimension, to restore occlusion, or if radiographs show poor endodontic prognosis or approximately two‑thirds or more bone loss at the site.

Members under age 14 not covered unless clinical rationale provided.

Documentation and frequency: Required documentation includes pre‑operative periapical x‑ray (or post‑op endo periapical x‑ray if endodontically treated) and detailed narrative; frequency limited to one onlay OR crown per tooth per five‑year period.

inv-15: Prophylaxis/Cleaning

Routine prophylaxis: Most groups cover two prophylaxis services per member per calendar year (D1110 adult, D1120 child); D4346 counts toward this limit and the combination cannot exceed the calendar year limitation.2 per calendar year

Bundling with SRP: Prophylaxis performed same day, by same dentist, as two or more limited sites or one or more quadrants of scaling and root planing is considered integral and may not be billed separately.

inv-16: Denture Rebase/Reline

Initial reline/rebase exclusion period: A rebase or reline performed within six months of denture delivery is considered part of the initial fee and a participating dentist may not charge the member (exception for immediate denture codes D5130/D5140).

Frequency limitation: Benefit for rebase or reline is limited to once per 36 months per arch; additional procedures within 36 months are not covered and are member liability.Once per 36 months per arch

inv-17: Distal or Proximal Wedge

Indication: Distal or proximal wedge (D4274) is performed in an edentulous area adjacent to a periodontally involved tooth to remove a tissue wedge, correct underlying osseous defects and permit close flap adaptation; report D4274 when not performed with other surgical procedures in the same anatomical area.

inv-18: Distal/Proximal Wedge - Coverage and Frequency

Distal/proximal wedge procedure coverage conditions

Distal wedge covered conditions: D4274 is covered when performed appropriately and limited to once per site per 36 months; distal wedge procedures performed more than once per site within 36 months are not covered and are member liability.Once per site per 36 months

If performed same day, same dentist as other periodontal surgery in same area, it is considered integral and not separately billable.

inv-19: Endodontic Retreatment - Coverage

Endodontic retreatment coverage conditions

Retreatment billing rules: Retreatment codes (D3346–D3348) are covered but limited to once per tooth per lifetime; retreatment performed by the same dentist within 12 months of the original RCT is considered integral and may not be billed to the member, whereas retreatment by a different dentist is allowed.Once per tooth per lifetime; same‑dentist integral within 12 months

Documentation requirement: Pre‑operative and post‑operative periapical x‑rays and a detailed narrative are required for endodontic retreatment claims; Dentist Advisor review required only when retreatment is provided within 30 days prior to an extraction.

inv-20: Endodontics on Primary Teeth - Coverage

Endodontics on primary teeth

Primary tooth root canal: Root canal therapy on primary teeth (D3230, D3240) is not a covered benefit and is considered member liability, except when there is no permanent successor — such exceptions will be reviewed by the Dentist Advisor.

Preoperative periapical x‑ray required for exception review.

inv-21: Pulpal therapy exceptions (D3230, D3240)

Covered when ALL of the following are met

Pulpal therapy exception: Pulpal therapy (D3230, D3240) may be considered when the primary tooth has no permanent successor; these exceptions require Dentist Advisor review and preoperative periapical x‑ray documentation.Once per tooth per lifetime when no permanent successor

inv-22: Extractions (D7111, D7140)

Extractions: Codes D7111 and D7140 (extractions) require no review for coverage; extractions include local anesthesia, suturing if needed, and routine post‑operative care. Failed extraction attempts (tooth not entirely removed) are not payable.

inv-23: Fixed Partial Dentures (pontics, bridges)

Fixed partial dentures - general: Fixed partial dentures (bridges and pontics) are subject to Dentist Advisor evaluation for pontic need and abutment support; pontics replacing teeth beyond the normal complement are not covered and are member liability.One per site every 60 months

Not covered for members under age 14 unless clinical rationale is provided; Dentist Advisor may deny a bridge if abutment support is inadequate.

inv-24: Full Mouth Debridement (D4355)

Covered when ALL of the following are met:

D4355 coverage criteria: Full mouth debridement (D4355) is intended to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit and is covered once per lifetime.Once per lifetime

D4355 is denied as integral if performed same day, same dentist as prophylaxis (D1110) or scaling and root planing (D4341/D4342); sequencing and timing restrictions apply.

inv-25: Gingival Flap Procedure (D4240/D4241)

Covered when ALL of the following are met:

D4240/D4241 coverage criteria: Gingival flap procedures (D4240/D4241) require Dentist Advisor review, are limited to once per 36 months per mouth area, and require pre‑treatment radiographs and periodontal charting; more than two quadrants on the same date require explanation.Once per 36 months per mouth area

Additional periodontal procedures at same site within 36 months are not covered and are member liability.

inv-26: Fixed Partial Denture Sectioning (D9120)

D9120 coverage stance: Fixed partial denture sectioning (D9120) is not covered and is considered member liability.

inv-27: Frenulectomy/Frenuloplasty (D7960/D7963)

D7960/D7963 coverage stance: Frenulectomy (D7960) and frenuloplasty (D7963) are covered; they are integral to each other and, when performed same day by same dentist with endodontic, oral surgery or periodontal surgery, are considered integral and may not be billed separately to the member.

No Dentist Advisor review required in routine cases.

inv-28: Gingivectomy / Periodontal procedure coverage

Coverage and frequency rules for gingivectomy/periodontal procedures

Frequency and limitation: Gingivectomy and related periodontal procedures are limited to one treatment per site/area in a 36‑month period; additional periodontal procedures at the same site within 36 months are not covered and are member liability.36 months

Integral procedures: If performed by the same dentist on the same date of service in the same mouth area as extractions, periodontal surgery (except soft tissue grafts), oral surgery, scaling/root planing, osseous surgery or flap surgery, the gingivectomy/procedure is considered integral to the more comprehensive procedure and may not be billed separately to the member.same date/same area

inv-29: Guided Tissue Regeneration (D4266/D4267)

Guided tissue regeneration coverage

Indication: Guided tissue regeneration for natural teeth (D4266/D4267) is covered when used to treat specific periodontal defects.per site

This procedure does not include flap entry/closure, wound debridement, osseous contouring or bone grafts which should be reported separately.

inv-30: Gold foil / Inlay coverage

Gold foil and inlay restorations coverage stance

Gold foil not covered: Gold foil restorations (D2410–D2430) are not covered and are considered member liability.

Patient consent and documentation of payment responsibility recommended.

Inlay allowance: Metallic and composite inlays are not a covered benefit; an allowance for the corresponding amalgam restoration may be applied and the patient is responsible for the difference up to the dentist's charge.

inv-31: Guided Tissue Regeneration - Covered Indication

Covered to treat specific periodontal defects.

GTR Coverage: Guided tissue regeneration (D4266/D4267) is a covered benefit when indicated to treat specific periodontal defects; frequency is once per site per lifetime and additional GTR in same site is not covered.once per site per lifetime

Not covered when performed in conjunction with extraction, cyst removal, apicoectomy or implants.

inv-32: Hemisection - Internal Policy

Hemisection Coverage: Hemisection (D3920) is covered as described; replacement of the missing section with a crown or pontic is not a covered benefit and is considered member liability.

Dentist Advisor may evaluate prognosis and related services.

inv-33: Immediate Dentures - Coverage

Immediate Dentures Coverage: Immediate dentures (D5130, D5140) include benefit for one laboratory reline within six months of insertion; frequency limited to once per arch in a five‑year period and no review is required.Once per arch per 5 years

Insertion date is completion date for benefit payment; specialized procedures are not covered.

inv-34: Implant Services - Conditional Coverage

Implant Services Coverage: Implant services are covered only if the group contract includes an implant rider; where purchased, implant coverage is subject to a $3,500 lifetime maximum and typically covered at 50% with all implant services subject to Dentist Advisor review.$3,500 lifetime maximum

Providers must follow documentation and review requirements; implant services otherwise are not covered.

inv-35: General implant placement criterion

Covered when ALL of the following are met

Successful implant placement: General implant placement requires successful placement to support or stabilize a prosthesis; implant removal is reviewed on an individual consideration basis taking into account time, difficulty and materials used.

Dentist Advisor reviews removal requests individually.

inv-36: Coverage determinations

Interim prostheses (e.g., D5810–D5821) are not covered and are considered member liability.

Internal root repair (perforation): Perforation repairs that occur during root canal treatment and are performed by the same dentist may be considered integral to the endodontic treatment and not separately billable; treatment of natural resorptive defects is considered a separate benefit.

Pre‑ and post‑op periapical x‑rays and narrative required for review.

Labial veneers (D2960–D2962) are not covered and are considered member liability.

Miscellaneous services: Multiple miscellaneous service codes listed (D9128–D9985 as specified) are not covered and are member liability; denture cleaning/inspection codes D9932–D9935 are considered integral to the examination and may not be billed separately.

inv-37: Not Covered / Member Liability

Procedures listed are non-covered and considered member liability unless otherwise noted as integral to a greater procedure

Non-covered codes: CDT codes listed in the policy (see sections) are designated as not covered and are considered member liability unless explicitly noted as integral to a greater procedure.

Refer to individual code entries for specifics and integral exceptions.

inv-38: Integral / Not Separately Billable

Certain procedures are considered integral to greater procedures and may not be separately billed by participating dentists

Integral billing rules: Specific services (e.g., denture cleaning/inspection D9932–D9935; gingival irrigation D4921; certain evaluation/re‑evaluation codes) are considered integral to broader procedures and a participating dentist may not bill the member separately.

D4381 is integral when reported with D7000–D7999.

inv-39: Bone replacement grafts (D4263/D4264)

Covered when ALL of the following are met:

Bone graft coverage criteria: Bone replacement grafts (D4263/D4264) involve use of osseous autografts/allografts or non‑osseous grafts to stimulate periodontal regeneration for bone deformity; a single site is one contiguous area and non‑contiguous areas may be reported as additional sites.1 per site per 36 months

Dentist Advisor review required for multiple bone grafts performed on the same day by the same dentist; not covered within 36 months following periodontal surgery in same mouth area.

inv-40: Occlusal guards

Covered only when specified by the group/plan and when evidence shows dental damage from clenching/grinding:

Occlusal guard coverage: Occlusal guards (nightguards) are covered only if the group/plan specifies coverage and when clinical evidence shows dental damage from clenching/grinding; if covered, limited to once in a 5‑year period; not covered to treat TMJ dysfunction, sleep apnea, snoring or as athletic mouthguards.Once per 5 years

Many occlusal and sleep/apnea related codes remain not covered unless plan specifies.

inv-41: Onlays

Covered when ALL of the following are met:

Onlay coverage: Onlays are allowed on permanent posterior teeth when the tooth has three surfaces involved and less extensive restorations (amalgam/composite) are inadequate; tooth must have sound endodontic and periodontal prognosis; replacement limited to one onlay OR crown per tooth per five‑year period.One onlay or crown per tooth per 5 years

Pre‑operative radiograph and detailed narrative required; dentist advisor review may be applied.

inv-42: Oral evaluations

Covered when contract/group allows:

Oral evaluation coverage: Most groups cover one oral examination per calendar year (D0120) performed by a general dentist; certain exam/screening codes (D0160, D0180, D0190, D0191) are not covered and are considered member liability; re‑evaluations (D0170/D0171) are integral to initial procedures and not separately billable.Once per calendar year

For D0150 full allowance applies if no active treatment by same dentist in past 3 years; otherwise allowance equals periodic evaluation.

inv-43: Osseous surgery (initial)

Osseous surgery is covered when ALL of the following are met:

Osseous surgery coverage criteria: Osseous surgery (D4260/D4261) is a benefit when patient exhibits moderate to advanced periodontal disease with pocket depths ≥5 mm and radiographic evidence of interproximal and/or vertical bone loss; Dentist Advisor review required to determine code selection based on number of qualifying contiguous teeth per quadrant.pocket depths >= 5mm

Limited to once per mouth area per 36 months; not covered if performed within 36 months of prior osseous surgery/grafting/GTR in same area.

inv-44: Orthodontics - eligibility and payment

Orthodontic benefit rules (when covered):

Orthodontic dependent eligibility: Dependents up to age 19 may be eligible when the specific contract includes orthodontic coverage; benefits continue until December 31 of the year of the member's 19th birthday and are subject to a separate lifetime orthodontic maximum allowance.age <= 19 when covered

Adult orthodontic coverage may be group specific.

Payment timing and continuation: Initial payment is submitted at banding/appliance placement and subsequent payments are processed in installments (quarterly) for treatment in progress; subscriber must be enrolled each month payments are made.

Claims for transfers/new enrollees require treatment plan, total fee, banding date and estimated duration.

inv-45: Oral pathology laboratory - coverage stance

Oral pathology laboratory procedures:

Oral pathology lab not covered: Oral pathology laboratory accessioning and microscopic/expert testing codes (D0472–D0502, D0480–D0486, D0999) are not covered because they represent laboratory procedures that do not include tissue removal and are considered member liability; individual consideration (I.C.) may be available for unspecified procedures (D0999).

inv-46: Evaluation codes - not covered / integral services

Evaluation and screening codes coverage stance:

Not covered exam codes: Specific exam/screening codes (D0160, D0180, D0190, D0191) are explicitly listed as not covered and are considered member liability; re‑evaluation codes D0170/D0171 are integral to initial procedures and may not be billed separately by a participating dentist.

Once per calendar year frequency applies for standard oral evaluations unless contract specifies otherwise.

The policy lists several restorative-related CDT codes that are explicitly not covered and therefore are the member's financial responsibility: D2976 (band stabilization), D2989 (excavation resulting in determination of non‑restorability), and D2990 (resin infiltration of incipient lesions). The code D2991 (application of hydroxyapatite regeneration medicament) has an age- and frequency-based limit: 2 per tooth per 12 months for ages 1–6; 1 per tooth per 12 months for ages 7–12.

Anatomical crown exposure codes D4230 and D4231 are explicitly not covered and are considered member liability when billed. Anesthesia-related billing is restricted: basic local/regional anesthesia codes (e.g., D9210, D9211, D9215) are integral to procedures and may not be billed separately, while certain sedation/general anesthesia codes are covered only with qualifying procedures and may require review. Certain enteral/moderate sedation and nitrous oxide administration (D9230, D9244, D9245) are not covered and are member liability.

Guided tissue regeneration performed in conjunction with periradicular surgery (D3432) is explicitly not covered and is member liability. Similarly, coping (D2975) is listed as a non‑covered benefit and the patient is responsible for payment when billed separately.

Core build-ups (D2950) have age and dentition restrictions: they are not covered for members under age 14 (unless clinical rationale is provided) and are not covered on primary teeth; such services are considered member liability.

The policy reiterates that specialized restorative procedures (for example, porcelain labial margins) are considered non‑covered and patient payment responsibility should be documented. In addition, crowns placed for cosmetic reasons or when the member is under age 14 are generally not covered unless an individual clinical rationale is provided.

Therapeutic parenteral drug and medicament codes (D9610, D9612, D9613, D9630) are listed as not covered and are considered member liability when submitted.

Pulpal therapy codes for primary teeth (D3230, D3240) are generally not covered and considered member liability. Exceptions may be reviewed by the Dentist Advisor when no permanent successor exists; documentation (preoperative periapical radiograph) is required for such review.

Provisional pontic (D6253) and provisional retainer crown requiring further treatment prior to final impression (D6793) are explicitly not covered and considered member liability when billed.

Fixed partial dentures (bridges and their components) are not covered for members under age 14 unless a documented clinical rationale is provided; such services billed for members under age 14 are considered member liability.

Bridges placed in the same treatment area within the five‑year frequency limit (one per site every 60 months) are not covered and are member liability. D9120 (fixed partial denture sectioning) is explicitly not covered and considered member liability.

Additional periodontal procedures performed at the same site within 36 months are not covered and are considered member liability. Gingivectomy/periodontal procedures performed on the same date, same area as more comprehensive procedures (e.g., osseous surgery, extractions, scaling/root planing) are considered integral to the comprehensive procedure and may not be billed separately to the member.

Guided tissue regeneration codes D4266 and D4267 are covered to treat specific periodontal defects, but subject to documentation and a frequency limit of once per site per lifetime. Guided tissue regeneration is not covered when performed in conjunction with extraction, cyst removal, apicoectomy or implants and is considered member liability in those situations.

Hemisection (D3920) is described as a covered procedure; however, replacement of the missing section of the tooth with a crown or pontic following hemisection is not covered and is considered member liability.

Immediate dentures (D5130, D5140) are a covered benefit with an allowed laboratory reline within six months of insertion. Frequency for immediate dentures is limited to once per arch in a 5‑year period; additional immediate dentures within that five‑year window are not covered and are member liability.

The policy provides an explicit list of miscellaneous and administrative codes that are not covered and are member liability (examples include D9128–D9129, D9130, D9910–D9914, D9920, D9930, D9941–D9942, D9950–D9952, D9961, D9970–D9975, D9985). Billing these codes may result in denial and member charge.

Interim prostheses (e.g., D5810–D5821) and labial veneers (D2960–D2962) are explicitly not covered and are considered member liability. Many other listed miscellaneous services are also non‑covered; see the policy code lists for specifics.

Certain minor services are considered integral to a greater procedure and may not be billed separately by a participating dentist. Examples: D4921 (gingival irrigation) is integral to greater procedures and D4381 is integral when reported with D7000–D7999; participating dentists may not bill the member separately for these services.

Biologic materials to aid tissue regeneration (D4265) are not covered and are member liability. Occlusal guard and sleep/apnea related codes are generally not covered unless the group/plan explicitly specifies coverage; when covered, occlusal guards are limited to once per 5 years. Several onlay two‑surface codes may not be covered or may receive an alternate benefit (e.g., amalgam). Certain evaluation codes (D0160, D0180, D0190, D0191) and oral pathology laboratory processing codes (D0472–D0502, D0480–D0486, D0999) are not covered and are considered member liability.

Osseous surgery (D4260/D4261) is not covered if performed within 36 months of prior osseous surgery, grafting or guided tissue regeneration in the same mouth area; such services in the restricted window are considered member liability. The general frequency rule for osseous surgery is once per mouth area per 36 months.

The policy lists multiple exam, oral pathology laboratory, and orthodontic ancillary codes that are explicitly not covered and are member liability (see D0160, D0180, D0190, D0191 for exams; D0472–D0502, D0480–D0486, D0999 for oral pathology lab; and D8660, D8681, D8690–D8699, D8701–D8704 for orthodontic ancillary services).

Some codes are labeled in the document as not covered or limited rather than explicitly being termed 'not medically necessary.' Review the specific exclusion and limitations lists: codes such as D2976, D2989, D2990 are listed as not covered/member liability and frequency-limited codes (e.g., D2991) carry age-based limits.

Anatomical crown exposure procedures (D4230, D4231) are explicitly identified as not covered; claims for these codes will be denied as a covered benefit and the member is financially responsible.

Core build-ups are not covered on primary teeth and are not covered for members under age 14 unless a documented clinical rationale is provided; such services are considered member liability.

Crowns placed solely for cosmetic reasons (including 'peg lateral'), to increase vertical dimension, to restore occlusion, or to correct congenital defects may be contractually denied; the patient would be responsible for payment in those situations unless an imminent pulpal indication exists.

Radiographic evidence of a poor endodontic prognosis or approximately two‑thirds or greater bone loss at the site will result in denial of major restorative procedures (patient/member liable); the policy lists specific radiographic and clinical factors used to assess prognosis (pocket depths, mobility, bone density, root condition, furcation involvement, ongoing periodontal therapy, patient age).

Distal or proximal wedge procedures (D4274) are limited to once per site per 36 months. When performed more than once at the same site within 36 months, they are not covered and are considered member liability.

Pulpal therapy on primary teeth (D3230, D3240) is not covered and is considered member liability; exceptions for a retained primary tooth without a permanent successor will be reviewed by the Dentist Advisor and require preoperative periapical radiographs for consideration.

Pontics that replace teeth beyond the normal complement are not benefitted; extra pontics are not covered and are considered member liability. The need for pontics and adequacy of abutment support are evaluated by the Dentist Advisor and may result in denial if abutment support is inadequate.

Full mouth debridement (D4355) is limited to once per lifetime and will be denied as integral if performed the same day by the same dentist as prophylaxis (D1110) or scaling and root planing (D4341/D4342). Related sequence restrictions apply to other periodontal procedures (e.g., D4346 considered integral within certain time windows).

A gingivectomy is not benefitted when performed at the same treatment site as a crown lengthening procedure and, when performed on the same date/area as more comprehensive periodontal or restorative procedures, is considered integral and not separately payable.

Guided tissue regeneration performed in conjunction with periradicular surgery should be reported under D3432; GTR in these settings is not covered and is considered member liability. Additional GTR in the same site is not covered and is member liability.

Incomplete endodontic therapy for an inoperable/unrestorable or fractured tooth (D3332) is not covered and is considered member liability. Fracture‑related procedures that lack adequate time to establish prognosis may be denied.

Labial veneers (codes D2960–D2962) are commonly cosmetic and are explicitly not covered; claims for these codes are considered member liability.

The policy includes an extensive list of miscellaneous codes that are not covered and considered member liability; providers should reference the code lists before billing as many administrative, cosmetic, teledentistry and adjunctive codes (e.g., D9128–D9129, D9936, D9944–D9946, D9953–D9959, D9972–D9975) will be denied if billed.

Occlusal guards (nightguards) are covered only when the group/plan specifies coverage and there is clinical evidence that clenching/grinding has damaged the dentition; if covered, replacement is limited to once per 5 years. Occlusal guards used to treat TMJ dysfunction, sleep apnea, snoring, or as athletic mouthguards are not covered and are member liability.

The policy restates that osseous surgery is not covered if performed within 36 months of prior osseous surgery, grafting or guided tissue regeneration in the same mouth area; such services are member liability and the standard frequency is once per mouth area per 36 months.

The document flags specific therapeutic parenteral drug codes (D9610, D9612, D9613, D9630) as not covered and considered member liability; providers should avoid billing these to the payer unless otherwise authorized.

Coding and Code Tables

D2971 - Additional proceduresCDT

D2971

Additional procedures to construct new crown under existing partial denture framework

Denture adjustmentsCDTCovered

D5410	Adjust complete denture-maxillary
D5411	Adjust complete denture-mandibular
D5421	Adjust partial denture-maxillary
D5422	Adjust partial denture-mandibular

Alveoloplasty codesCDTCovered

D7310	Alveoloplasty in conjunction with extractions-four or more teeth or tooth spaces, per quadrant
D7311	Alveoloplasty in conjunction with extractions-one to three teeth or tooth spaces, per quadrant
D7320	Alveoloplasty not in conjunction with extractions-four or more teeth or tooth spaces, per quadrant
D7321	Alveoloplasty not in conjunction with extractions-one to three teeth or tooth spaces, per quadrant

Amalgam and Composite codesCDT

D2140	Amalgam-one surface, primary or permanent
D2150	Amalgam-two surfaces, primary or permanent
D2160	Amalgam-three surfaces, primary or permanent
D2161	Amalgam-four or more surfaces, primary or permanent
D2330	Resin-based composite-one surface, anterior
D2331	Resin-based composite-two surfaces, anterior
D2332	Resin-based composite-three surfaces, anterior
D2335	Resin-based composite-four or more surfaces, anterior
D2390	Resin-based composite crown, anterior
D2391	Resin-based composite-one surface, posterior

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Anatomical crown exposureCDTNot Covered

D4230	Anatomical crown exposure-four or more contiguous teeth per quadrant: Not covered and is member liability.
D4231	Anatomical crown exposure-one to three teeth per quadrant: Not covered and is member liability.

Anesthesia / Sedation codesCPT

D9210	Local anesthesia not in conjunction with operative or surgical procedures: Integral to the greater procedure. A participating dentist may not bill the member.
D9211	Regional block anesthesia: Integral to the greater procedure. A participating dentist may not bill the member.
D9212	Trigeminal division block anesthesia: Integral to the greater procedures. A participating dentist may not bill the member.
D9215	Local anesthesia in conjunction with operative or surgical procedures: Integral to the greater procedure. A participating dentist may not bill the member.
D9219	Evaluation for deep sedation or general anesthesia: Integral to administration of the anesthesia. A participating dentist may not bill the member.
D9222	Administration of deep sedation/general anesthesia - first 15 min increment, or any portion thereof (with, or without co-administration of nitrous oxide)
D9223	Administration of deep sedation/general anesthesia - each additional 15 min increment, or any portion thereof (with, or without co-administration of nitrous oxide)
D9224	Administration of general anesthesia with advanced airway - first 15-minute increment, or any portion thereof: Covered, subject to individual consideration by Dental Consultant review.
D9225	General anesthesia with advanced airway - each subsequent 15-minute increment, or any portion thereof: Covered, subject to individual consideration by Dental Consultant review.
D9230	Administration of nitrous oxide (when nitrous oxide is administered as a single agent): Not covered and is considered member liability.

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Apexification/Recalcification & Pulpal regenerationCPT

D3351	Apexification/recalcification- initial visit (includes opening tooth, preparation of canal spaces, first placement of medication and necessary radiographs).
D3352	Apexification/recalcification - visits with replacement of intra-canal medication and necessary radiographs.
D3353	Apexification/recalcification-final visit (include completed root canal therapy-apical closure/calcific repair of perforations, root resorption, etc.)
D3355	Pulpal regeneration - initial visit (includes opening tooth, preparation of canal spaces, placement of medication).
D3356	Pulpal regeneration - interim medication replacement.
D3357	Pulpal regeneration - completion of treatment (does not include final restoration).

Apically positioned flapCPT

D4245

Apically positioned flap. Considered integral to the greater procedure. A participating dentist may not bill a member.

Apically positioned flapCDTCovered

D4245

Apically positioned flap

Periradicular surgery codesCDT

D3410	Apicoectomy-anterior
D3421	Apicoectomy-bicuspid (first root)
D3425	Apicoectomy-molar (first root)
D3426	Apicoectomy-(each additional root)
D3427	Periradicular surgery without apicoectomy
D3432	Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery: Not covered and is considered member liability.

Complete denture codesCDTCovered

D5110	Complete denture-maxillary
D5120	Complete denture-mandibular

CopingCDTNot Covered

D2975

Coping: Not covered and is considered member liability.

Core build-upCDTCovered

D2950

Core buildup, including any pins

Crown lengthening codesCDTCovered

D4249

Clinical crown lengthening-hard tissue

Crown repair codesCDT

D2980	Crown repair necessitated by restorative material failure
D2981	Inlay repair necessitated by restorative material failure
D2982	Onlay repair necessitated by restorative material failure
D2983	Veneer repair necessitated by restorative material failure: Not covered and is considered member liability.

Crown procedure codesCDTCovered

D2710	Crown-resin-based composite (indirect)
D2712	Crown-3/4 resin-based composite (indirect)
D2720	Crown-resin with high noble metal
D2721	Crown-resin with predominantly base metal
D2722	Crown-resin with noble metal
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
D2753	Crown - porcelain fused to titanium and titanium alloys

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Covered CDT Crown CodesCPTCovered

D2710	Crown-resin-based composite (indirect)
D2712	Crown-3/4 resin-based composite (indirect)
D2720	Crown-resin with high noble metal
D2721	Crown-resin with predominantly base metal
D2722	Crown-resin with noble metal
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
D2753	Crown - porcelain fused to titanium and titanium alloys

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Prophylaxis CodesCPTCovered

D1110	Prophylaxis - adult (age 13 or older are eligible for this code)
D1120	Prophylaxis - child (no upper age limit)

Denture Rebase/Reline CodesCPTCovered

D5710	Rebase complete maxillary denture
D5711	Rebase complete mandibular denture
D5720	Rebase maxillary partial denture
D5721	Rebase mandibular partial denture
D5730	Reline complete maxillary denture (chairside)
D5731	Reline complete mandibular denture (chairside)
D5740	Reline maxillary partial denture (chairside)
D5741	Reline mandibular partial denture (chairside)
D5750	Reline complete maxillary denture (laboratory)
D5751	Reline complete mandibular denture (laboratory)

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Distal/Proximal Wedge ProcedureCPTCovered

D4274

Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)

Periodontal - Distal/Proximal WedgeCPTCovered

D4274

Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)

Drug-related codes (Not covered)CPTNot Covered

D9610	Therapeutic parenteral drug, single administration: Not covered and is considered member liability.
D9612	Therapeutic parenteral drugs, two or more administrations, different medications: Not covered and is considered member liability.
D9613	Infiltration of sustained release therapeutic drug- single or multiple sites: Not covered and is considered member liability.
D9630	Other drugs and/or medicaments, by report: Not covered and is considered member liability.

Endodontic retreatmentCPTCovered

D3346	Retreatment of previous root canal therapy - anterior
D3347	Retreatment of previous root canal therapy - bicuspid
D3348	Retreatment of previous root canal therapy - molar

Endodontics on primary teeth (Not covered)CPTNot Covered

D3230	Pulpal therapy (resorbable filling)-anterior, primary tooth (excluding final restoration): Not covered and is considered member liability.
D3240	Pulpal therapy (resorbable filling)-posterior, primary tooth (excluding final restoration): Not covered and is considered member liability.

Pulpal therapy (primary teeth)CPTNot Covered

D3230	Pulpal therapy (resorbable filling)-anterior, primary tooth (excluding final restoration): Not covered and is considered member liability.
D3240	Pulpal therapy (resorbable filling)-posterior, primary tooth (excluding final restoration): Not covered and is considered member liability.

ExtractionsCPTCovered

D7111	Extraction, coronal remnants-deciduous tooth
D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

Fixed Partial Denture components (pontics, retainers, inlays/onlays, crowns)CPT

D6205	Pontic-indirect resin-based composite (Not be used as a temporary or provisional prosthesis)
D6210	Pontic-cast high noble metal
D6211	Pontic-cast predominantly base metal
D6212	Pontic-cast noble metal
D6214	Pontic-titanium
D6240	Pontic-porcelain fused to high noble metal
D6241	Pontic-porcelain fused to predominantly base metal
D6242	Pontic-porcelain fused to noble metal
D6243	Pontic- porcelain fused to titanium and titanium alloys
D6245	Pontic-porcelain/ceramic

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Not CoveredCPTNot Covered

D9120

Fixed partial denture sectioning: Not covered and is considered member liability.

Covered CPT CodesCPTCovered

D7960	Frenulectomy (also known as a frenectomy or frenotomy)
D7963	Frenuloplasty

Covered CPT CodesCPTCovered

D4355

Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit.

Covered CPT CodesCPTCovered

D4240	Gingival flap procedure, including root planing-four or more contiguous teeth or tooth bounded spaces per quadrant
D4241	Gingival flap procedure, including root planing-one to three contiguous teeth or tooth bounded spaces per quadrant

Gingivectomy codesCPTCovered

D4210	Gingivectomy or gingivoplasty-four or more contiguous teeth or tooth bounded tooth spaces per quadrant
D4211	Gingivectomy or gingivoplasty-one to three contiguous teeth or tooth bounded tooth spaces per quadrant
D4212	Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth: Considered integral to the restorative procedure. A participating dentist may not bill the member.

Gold foil and inlay codesCPT

D2410	Gold foil-one surface: Not covered and is considered member liability.
D2420	Gold foil-two surface: Not covered and is considered member liability.
D2430	Gold foil-three surface: Not covered and is considered member liability.
D2510	Inlay-metallic-one surface
D2520	Inlay-metallic-two surfaces
D2530	Inlay-metallic-three or more surfaces
D2610	Inlay-porcelain/ceramic-one surface
D2620	Inlay-porcelain/ceramic-two surfaces
D2630	Inlay-porcelain/ceramic-three or more surfaces
D2650	Inlay-resin-based composite-one surface

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Guided tissue regeneration codesCPTCovered

D4266	Guided tissue regeneration, natural teeth - resorbable barrier, per site
D4267	Guided tissue regeneration, natural teeth - non-resorbable barrier, per site

Covered CDT Codes - HemisectionCPTCovered

D3920

Hemisection (including any root removal), not including root canal therapy

Covered CDT Codes - Immediate DenturesCPTCovered

D5130	Immediate denture-maxillary
D5140	Immediate denture-mandibular

Covered CDT Codes - Implant services (requires rider)CPTCovered

D6010	Surgical placement of implant body: endosteal implant
D6011	Second stage implant surgery
D6012	Surgical placement of interim implant body for transitional prosthesis: endosteal implant
D6013	Surgical placement: mini-implant
D6040	Surgical placement: eposteal implant
D6049	Scaling and debridement of a single implant in the presence of peri-implantitis inflammation, bleeding upon probing and increased pocket depths, including cleaning of the implant surfaces, without flap entry and closure
D6050	Surgical placement: transosteal implant
D6051	Placement of interim implant abutment
D6052	Semi-precision attachment abutment
D6055	Connecting bar - implant supported, or abutment supported utilized to stabilize and anchor a prosthesis.

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Interim prosthesis codesCPTNot Covered

D5810	Interim complete denture (maxillary): Not covered and is considered member liability.
D5811	Interim complete denture (mandibular): Not covered and is considered member liability.
D5820	Interim partial denture (maxillary): Not covered and is considered member liability.
D5821	Interim partial denture (mandibular): Not covered and is considered member liability.

Internal root repairCPT

D3333

Internal root repair of perforation defects

Labial veneersCPTNot Covered

D2960	Labial veneer (resin laminate)-chairside: Not covered and is considered member liability.
D2961	Labial veneer (resin laminate)-laboratory: Not covered and is considered member liability.
D2962	Labial veneer (porcelain laminate)-laboratory: Not covered and is considered member liability.

Miscellaneous servicesCPTNot Covered

D9128	Photobiomodulation therapy - first 15-minute increment, or any portion thereof: Not covered and is considered member liability.
D9129	Photobiomodulation therapy - each subsequent 15-minute increment, or any portion thereof: Not covered and is considered member liability.
D9130	Temporomandibular joint dysfunction- non-invasive physical therapies: Not covered and is considered member liability.
D9910	Application of desensitizing medicament: Not covered and is considered member liability.
D9911	Application of desensitizing resin for cervical and/or root surface, per tooth: Not covered and is considered member liability.
D9913	Administration of neuromodulators: Not covered and is considered member liability.
D9914	Administration of dermal fillers: Not covered and is considered member liability.
D9920	Behavior management, by report: Not covered and is considered member liability.
D9930	Treatment of complications (post-surgical)-unusual circumstances, by report: Not covered and is considered member liability.
D9932	Cleaning and inspection of removable complete denture, maxillary: Considered integral to the examination. A participating dentist may not bill the member.

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Provider Actions, Documentation & Review

Denial Risk

Codes flagged for noncoverage or limited coverage

Certain CDT procedure codes are explicitly not covered or are limited and will be considered member liability if rendered. Verify benefits prior to treatment and document exceptions when applicable.

Not covered / member liability examples: D2976, D2989, D2990, D2991 (limits by age), D3410-D3432 (D3432 GTR periradicular not covered), D4230, D4231, D9230, D9244, D9245 (and related moderate sedation wording), D9610-D9630, D3333 (see review rules), D2960-D2962 (labial veneers), D4265, D6081, D6085, D6197 (prosthetic replacement limit), D9128-D9129, D9130, D9910-D9914, D9920, D9930, D9941, D9942, D9950-D9952, D9961, D9970-D9975, D9985, many others listed in non-covered sections. Refer to specific code blocks for complete lists.
Some services are considered integral to a greater procedure and may not be billed separately to the member (examples: local/regional anesthesia when provided with operative/surgical procedures – D9210, D9211, D9212, D9215, study models and temporary crowns with definitive crowns/onlays, recementation within 12 months, interim prostheses).

Prior Authorization

Dentist Advisor review required for exceptions and pontics

Background

Guided tissue regeneration (GTR) for periradicular surgery (D3432) is not a covered adjunct to periradicular surgery and is member liability; similarly, certain coping services (D2975) are non‑covered when billed separately.

Definitions

Revision History

01/01/2016effective

Policy became effective on 01/01/2016 (document-wide effective date).

01/01/2026last_updatedLatest

Policy last updated on 01/01/2026 (document-wide last updated timestamp).

D3428	Bone graft in conjunction with periradicular surgery - per tooth, single site: Not covered and is considered member liability.
D3429	Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in same surgical site: Not covered and is considered member liability.
D3431	Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery: Not covered and is considered member liability.
D3460	Endodontic endosseous implant: Not covered and is considered member liability.
D3470	Intentional reimplantation (including necessary splinting): Not covered and is considered member liability.
D3910	Surgical procedure for isolation of tooth with rubber dam: Not covered and is considered member liability.
D3950	Canal preparation and fitting of performed dowel or post: Not covered and is considered member liability.

D4320	Provisional splinting - intracoronal
D4321	Provisional splinting - extracoronal
D4381	Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report
D4921	Gingival irrigation with a medicinal agent - per quadrant
D4263	Bone replacement graft - first site in quadrant
D4264	Bone replacement graft - each additional site in quadrant
D4265	Biologic materials to aid in soft and osseous tissue regeneration: Not covered

D9936	Cleaning and inspection of occlusal guard - per appliance: Not covered
D9938	Fabrication of a custom removable clear plastic temporary aesthetic appliance: Not covered and is considered member liability.
D9939	Placement of a custom removable clear plastic temporary aesthetic appliance: Not covered and is considered member liability.
D9943	Occlusal guard adjustment: Not covered and is considered member liability.
D9944	Occlusal guard - hard appliance, full arch: Not covered (unless group/plan specified) and is considered member liability.
D9945	Occlusal guard - soft appliance, full arch: Not covered (unless group/plan specified) and is considered member liability.
D9946	Occlusal guard - hard appliance, partial arch: Not covered (unless group/plan specified) and is considered member liability.
D9953	Reline custom sleep apnea appliance: Not covered and is considered a member liability.
D9954	Fabrication and delivery of oral appliance therapy (OAT) morning repositioning device: Not covered and is considered member liability.
D9955	Oral appliance therapy (OAT) titration visit: Not covered and is considered member liability.

D2542	Onlay-metallic-two surfaces: Not covered; may receive alternate benefit of amalgam.
D2543	Onlay-metallic-three surfaces
D2544	Onlay-metallic-four or more surfaces
D2642	Onlay-porcelain/ceramic-two surfaces: Not covered; may receive alternate benefit of amalgam.
D2643	Onlay-porcelain/ceramic-three surfaces
D2644	Onlay-porcelain/ceramic-four or more surfaces
D2662	Onlay-resin-based composite-two surfaces: Not covered; may receive alternate benefit of amalgam.
D2663	Onlay-resin-based composite-three surfaces
D2664	Onlay-resin-based composite-four or more surfaces

D0120	Periodic oral evaluation - established patient
D0140	Limited oral evaluation - problem focused
D0145	Oral evaluation for a patient under three years of age and counseling with primary caregiver
D0150	Comprehensive oral evaluations - new or established patient
D0160	Detailed and extensive oral evaluation - problem focused: Not covered
D0170	Re-evaluation - limited, problem focused: Integral to initial procedure
D0171	Re-evaluation - post operative visit: Integral to initial procedure
D0180	Comprehensive periodontal evaluation - new or established patient: Not covered
D0190	Screening of a patient: Not covered
D0191	Assessment of a patient: Not covered

OpenPayer

Blue Cross Dental Coverage and Clinical Policy — Selected Dental Procedures

Coverage Criteria

Coding and Code Tables

Provider Actions, Documentation & Review

Background

Definitions

Revision History

D0472	Accession of tissue, gross examination, preparation and transmission of written report
D0473	Accession of tissue, gross and microscopic examination, preparation and transmission of written report
D0474	Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report
D0480	Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report
D0486	Accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report
D0475	Decalcification procedure
D0476	Special stains for microorganisms
D0477	Special stains, not for microorganisms
D0478	Immunohistochemical stains
D0479	Tissue in-situ hybridization, including interpretation

D8010	Limited orthodontic treatment of the primary dentition
D8020	Limited orthodontic treatment of the transitional dentition
D8030	Limited orthodontic treatment of the adolescent dentition
D8040	Limited orthodontic treatment of the adult dentition
D8050	Interceptive orthodontic treatment of the primary dentition
D8060	Interceptive orthodontic treatment of the transitional dentition
D8070	Comprehensive orthodontic treatment of the transitional dentition
D8080	Comprehensive orthodontic treatment of the adolescent dentition
D8090	Comprehensive orthodontic treatment of the adult dentition
D8091	Comprehensive orthodontic treatment with orthognathic surgery

D4260	Osseous surgery (including flap entry and closure)-four or more contiguous teeth or tooth bounded spaces per quadrant
D4261	Osseous surgery (including flap entry and closure)-one to three contiguous teeth or tooth bounded spaces per quadrant