CurrentDelta Dental of OhioPolicy 282.36.v2

Clinical Criteria for Non-Pharmacologic Behavior Management

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Establishes clinical criteria for determining the medical necessity and clinical appropriateness of non-pharmacologic behavior guidance, including basic techniques and advanced protective stabilization, and governs provider documentation and coverage determinations when plan review is required.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Non-Pharmacologic Behavior Management

Policy CodePolicy 282.36.v2

Change TypeNo material change

Effective DateMay 9, 2025

Next Review DateNot specified

Key ActionWhen the dental plan requires medical-necessity review before payment, submit the clinical criteria and supporting documentation required by this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Applicable CDT procedure code

5Basic behavior guidance techniques described

2Behavior guidance categories

3Protective stabilization methods

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CurrentDelta Dental of OhioPolicy 282.36.v2

Clinical Criteria for Non-Pharmacologic Behavior Management

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Sign up for deltadentalofohio Policy 282.36.v2 alerts

Get alerted when Policy 282.36.v2 changes without checking for updates manually.

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Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Non-Pharmacologic Behavior Management

Policy CodePolicy 282.36.v2

Change TypeNo material change

Effective DateMay 9, 2025

Next Review DateNot specified

Key ActionWhen the dental plan requires medical-necessity review before payment, submit the clinical criteria and supporting documentation required by this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Applicable CDT procedure code

5Basic behavior guidance techniques described

2Behavior guidance categories

3Protective stabilization methods

6Required documentation categories

Behavior Guidance Coverage Criteria

Basic behavior guidance

Basic behavior guidance is generally considered indicated when the patient can be treated in the dental office but a documented condition requires non-pharmacologic intervention to avert behavior that would otherwise preclude safe, quality care.

Qualifying patient circumstances: The patient has one or more qualifying circumstances.
Examples include limited cooperation due to young age; high dental anxiety receptive to basic guidance; barriers to bidirectional verbal communication; cognitive disability limiting comprehension or following clinician directives; or emotional conditions causing uncooperative behavior that may improve with basic guidance.

Advanced behavior guidance: protective stabilization

Protective stabilization is indicated when advanced non-pharmacologic behavior guidance is necessary and the patient meets a qualifying clinical circumstance. Evaluate patient-specific risks, treatment needs, alternatives, and safety before use.

Protective stabilization indications: The patient is unsedated with uncontrolled movements detrimental to safely receiving quality dental care; is uncooperative and requires limited treatment for which sedation or general anesthesia is not an option; or requires urgent care with uncontrolled movements or uncooperative behavior due to level of development or mental conditions.

Protective stabilization safeguards: Protective stabilization is performed by clinicians with appropriate training and experience and applied consistently with AAPD requirements for objectives, indications, contraindications, alternate behavior guidance modalities, and patient-safety precautions.

Evaluate the patient's physical, medical, and psychological condition; contraindications to basic behavior guidance; dental condition and treatment needs; and the specific stabilization method. Use informed consent from the parent or responsible person and the least restrictive method consistent with safe treatment.

Procedure reporting requirements

D9920 reporting is appropriate only for specific non-pharmacologic interventions requiring resources beyond normal treatment.

D9920 reporting requirements: Additional clinical staff and/or additional time beyond normal staffing and/or treatment time are required to apply generally accepted non-pharmacologic behavior guidance techniques to alter or control patient actions for safe completion of necessary dental treatment.

Do not report D9920 for reassurance of a mild-to-moderately nervous patient, explanation or review of complex dental conditions or procedures, or additional treatment time unrelated to patient behavior issues. Report pharmacologic behavior guidance, including sedation and general anesthesia, using the appropriate procedure codes.

Pharmacologic-based advanced behavior guidance, including sedation and general anesthesia, is outside the coverage criteria addressed in this document.

Behavior guidance is not considered appropriate when used in circumstances that do not support safe completion of necessary dental treatment, including use on a cooperative unsedated patient, use solely for clinician or dental-team convenience, use of an inappropriate technique, or use when an alternative approach is more suitable.

Protective stabilization is subject to patient-safety and provider-qualification restrictions. It should not be used when restraint is contraindicated, when the clinician or dental team lacks appropriate education and experience, or when no treatment requiring stabilization is needed at the visit.

When the dental plan covers D9920, the code is not eligible for benefit payment when submitted with pharmacologic advanced behavior guidance procedures, including sedation or general anesthesia.

Basic or advanced behavior guidance should not be used on a cooperative unsedated patient.

Behavior guidance should not be used solely for the convenience of the clinician or dental team.

A behavior guidance technique is not medically necessary when it is inappropriate for the patient's condition or circumstances. Examples include attempting voice control with a hearing-impaired patient or using communicative guidance with a patient who has insufficient cognitive development.

Protective stabilization should not be used when the patient has a physical, medical, or psychological contraindication to restraint.

Protective stabilization should not be performed by a clinician or dental team that lacks the appropriate education and experience to use the technique safely.

Immobilization with a stabilization device is not medically necessary when no treatment requiring stabilization is needed at the particular dental visit.

Behavior guidance should not be used when an alternative approach is more appropriate, including deferral of treatment or pharmacologic behavior management.

D9920 should not be reported for reassurance of a mild-to-moderately nervous patient, for reviewing or explaining complex dental conditions or procedures, or for additional treatment time attributable to reasons other than patient behavior issues.

Applicable Procedure Code

Applicable Dental Procedure CodeCPT

D9920

behavior management, by report

Review, Documentation, and Billing Actions

Prior Authorization

Plan-Required Medical Necessity Review

When the member’s dental plan requires a determination by Delta Dental of Ohio, submit the behavior management claim for medical necessity and clinical appropriateness review before benefit payment. Delta Dental of Ohio applies any program-specific medical-necessity criteria or other coverage limitations established by the member’s dental benefit program.

Review the member’s specific dental benefit program to determine whether behavior management benefits are allowed, limited to particular patient conditions or techniques, or excluded.
Obtain the plan-required determination when applicable; coverage is not established solely by reporting a behavior management procedure code.

Documentation Required

Required Clinical Record and Claim Documentation

When benefit payment depends on medical-necessity or clinical-appropriateness review, submit the applicable clinical record information with the claim. The record should explain why behavior guidance was required for the particular patient and treatment episode.

Behavior Guidance Overview

Behavior guidance includes pharmacologic and non-pharmacologic techniques used to reduce anxiety, promote a positive dental attitude, establish communication, and provide safe and effective oral health care. This document addresses non-pharmacologic basic and advanced techniques, including protective stabilization; pharmacologic advanced techniques such as sedation and general anesthesia are outside its scope.

Key Definitions

Behavior guidance

DefinitionThe process of interacting with a patient to promote behavior conducive to achieving and maintaining good dental health.

Protective stabilization

DefinitionPhysical limitation of a patient's movement by a person or restrictive equipment, materials, or devices for a finite period of time in order to safely provide examination, diagnosis, and/or treatment.

Tell-show-do

DefinitionA technique that tells the patient about a pending dental procedure at an appropriate developmental or cognitive level, demonstrates its sensory elements in a nonthreatening manner, and then completes treatment as explained and demonstrated.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Non-Pharmacologic Behavior Management

Policy CodePolicy 282.36.v2

Change TypeNo material change

Effective DateMay 9, 2025

Next Review DateNot specified

Key ActionWhen the dental plan requires medical-necessity review before payment, submit the clinical criteria and supporting documentation required by this policy.

SourceLink

On This Page

Submit the diagnostic rationale and relevant patient factors, including age; physical, developmental, behavioral, psychological, or other limiting conditions; dental condition; planned treatment; and specific behavioral impediments to care delivery.
Document the behavior management techniques used, extra appointment time beyond normal treatment time, and any additional staff assistance required.
Base the decision to use behavior guidance on a thorough clinical and radiographic examination and an appropriate treatment plan.
Provide other relevant clinical information if requested by Delta Dental of Ohio.

Documentation Required

Protective Stabilization Records and Consent

Use protective stabilization only when basic behavior guidance is ineffective or unfeasible and stabilization is definitely needed to protect the patient or dental team while providing necessary care. Select the least restrictive method that permits safe treatment and use it only through trained clinicians and staff.

Obtain informed consent from the parent or responsible person and submit a copy of the signed consent form when protective stabilization is used.
Record the reason for stabilization, the device or method used, the duration of use, and the outcome.
Examples include wraps, supportive seat belts, and stabilization devices commonly known as papoose boards.

Denial Risk

Inappropriate or Unnecessary Behavior Guidance

Behavior guidance may be denied when it is inappropriate for the patient’s condition or circumstances, unnecessary for the visit, used for convenience, or provided when a safer or more appropriate alternative is available. Use only techniques supported by the patient’s needs and the treatment plan.

Do not use basic or advanced behavior guidance on a cooperative, unsedated patient or solely for clinician or dental-team convenience.
Do not use techniques inappropriate to the patient, such as voice control for a hearing-impaired patient or communicative guidance for a patient with insufficient cognitive development.
Do not use protective stabilization when the patient has a contraindicating physical, medical, or psychological condition, or when the clinician and team lack appropriate education and experience.
Do not immobilize a patient when treatment requiring stabilization is not needed at that visit; consider treatment deferral or pharmacological behavior management when more appropriate.

Billing Rule

Nonqualifying Use of D9920

Report D9920 only for specific non-pharmacologic behavior management interventions that require additional clinical staff and/or additional time beyond normal staffing or treatment time to alter or control patient actions for safe completion of necessary dental treatment.

Do not report D9920 for reassuring a mildly to moderately nervous patient.
Do not report D9920 for reviewing or explaining complex dental conditions or procedures.
Do not report D9920 for additional treatment time caused by reasons other than patient behavior issues.
Report advanced pharmacologic behavior guidance, including sedation and general anesthesia, using the appropriate procedure codes.

Denial Risk

Do Not Combine D9920 With Sedation or General Anesthesia

When covered by the member’s dental plan, D9920 is not eligible for benefit payment when submitted in conjunction with pharmacologic advanced behavior guidance procedures, including sedation or general anesthesia.

Do not combine D9920 with sedation or general anesthesia for benefit payment.

Denial Risk

Insufficient Clinical Documentation

If the practitioner cannot provide documentation supporting the medical necessity and clinical appropriateness of behavior management, Delta Dental of Ohio may disapprove benefit payment. Maintain complete records and submit the applicable supporting information with the claim.

Documentation must connect the behavior guidance intervention to the patient’s condition, the treatment episode, and the need for safe completion of necessary care.
Include the technique used, extra time, additional staff assistance, and signed informed consent when protective stabilization is used.

Billing Rule

Plan-Specific Benefit Limitation or Exclusion

Coverage of behavior management services depends on the member’s specific dental benefit program. Delta Dental of Ohio determines eligibility according to the program’s provisions, including any service-specific conditions, technique limitations, medical-necessity criteria, or exclusions.

A dental benefit program may cover behavior management only for specified patient conditions or particular behavior guidance techniques.
A program may exclude behavior management coverage in all circumstances or impose other limitations.
Apply the member’s program-specific criteria when evaluating medical necessity and benefit eligibility.