Establishment and Adoption of Utilization Review Criteria and Clinical Guidelines
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Defines the process by which DentaQuest develops, adopts, reviews, and applies written clinical criteria and guidelines for utilization management and medical necessity determinations affecting covered dental services and providers in DentaQuest-managed plans.
Policy Summary
Payerdentaquestdental
PolicyEstablishment and Adoption of Utilization Review Criteria and Clinical Guidelines
Policy CodePolicy UM01-INS
Change TypeNo material changes
Effective DateMay 1, 2018
Last ReviewSep 20, 2018
Next Review Date
Key ActionObtain prior authorization and provide required radiographs and a medical necessity narrative for services that require pre-authorization (for example, SPU cases, impacted third molar extractions, prosthetic services, nitrous oxide, general anesthesia, and orthodontics).
No material clinical or coverage changes in this revision.
45 daysCommittee opinion timeframe (new tech)
May 31Final annual approval deadline
AnnualPeer review frequency
All
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States applicability
5 yearsProsthesis replacement minimum age
36 monthsReline frequency
Coverage Criteria
inv-04: New and Emerging Technology — evaluation process and committee timelines
Requests for evaluation follow a formal review process and written opinion timelines.
Initiation and review: A formal evaluation for new or emerging diagnostic or treatment technologies may be initiated by the Clinical Director, a Provider, or a Plan (Client). The Peer Review Committee conducts the review and may invite subject matter experts as needed.
Committee Chairperson coordinates initial research and distribution of materials.
Evidence considered: The Peer Review Committee shall consider specialty society endorsement (e.g., ADA), FDA approval status where applicable, written opinion from the Plan when delegated, current state/CMS coverage status for Medicaid/Medicare populations, and written requests or supporting documentation from Providers and relevant specialists.
Decisions are evidence-driven and documented.
Committee opinion and timelines: The Peer Review Committee will provide a written opinion within 45 days of receipt of the evaluation request. Upon acceptance as a covered service, clinical guidelines will be formulated and submitted for Quality Oversight Committee/Plan approval as appropriate.45 days
Written opinion provided within 45 days of receipt.
inv-01: Exhibit A SPU Criteria — Short Procedure Units approval logic
Short Procedure Units (SPU) are approved when ANY of the following clinical situations apply; all SPU cases must be pre-authorized with narrative and documentation.
SPU approval conditions: A. Young children requiring extensive operative procedures when in-office sedation (nitrous oxide or IV) is inappropriate and hospitalization is not solely for controlling apprehension; B. Patients requiring extensive dental procedures classified ASA Class III or IV; C. Medically compromised patients needing monitoring or resuscitative equipment during procedures; D. Patients with uncontrolled bleeding, severe cerebral palsy, or other conditions rendering in-office treatment inappropriate; E. Patients with psychosomatic disorders requiring special treatment; F. Persons with cognitive disabilities with prior history indicating hospitalization; G. Hospitalized individuals needing extensive restorative or surgical procedures or physician-requested dental consult.
All SPU cases must be pre-authorized with narrative and supporting radiographs/documentation.
inv-02: Exhibit B Periodontal Clinical Criteria — scaling and root planing ALL criteria
Periodontal scaling and root planing (D4341/D4342) are covered when ALL of the following are met.
Attachment loss and radiographic evidence: Loss of clinical attachment, including radiographic evidence of bone loss. Probing depths are typically > 4 mm and attachment loss must be demonstrated (scaling and root planing are therapeutic, not prophylactic).> 4 mm
D4341/D4342 require evidence of attachment loss to be payable.
Documentation and timing: When requested, submit appropriate pre-operative radiographs (full mouth preferred) and periodontal charting dated within 12 months, plus a detailed treatment plan and treatment records.radiographs/charting within 12 months
Decisions made on basis of documentation provided.
Tooth and prognosis requirements: Benefits are available only when billed for natural teeth and the teeth must have a good long-term prognosis.
inv-03: Exhibit C Dental Extraction Clinical Criteria — extraction authorization criteria and limits
Extractions require specific documentation and are subject to coverage limitations; authorization is required for certain extractions.
Required documentation: Diagnostic-quality periapical and/or panoramic radiographs showing the entire tooth/teeth and opposing dentition must be submitted; radiographs must be mounted with patient name and date taken (not date of submission); duplicate radiographs must be labeled R/L when applicable. A narrative demonstrating medical necessity must accompany requests.radiographs mounted with patient name & date
In emergencies, same documentation required for retrospective review.
Non-covered extractions: Prophylactic removal of asymptomatic or disease-free teeth (including disease-free third molars) and removal of primary teeth whose exfoliation is imminent are not covered benefits.
Deferral when edentulous outcome expected: Extractions that will render a patient edentulous generally must be deferred until authorization to construct a denture has been given.
inv-05: Crown Coverage Criteria — post-endodontic and structural requirements
Crowns are covered when ALL of the following structural and post-endodontic conditions are met.
Structural thresholds for crown placement: Crowns are allowed only for teeth needing multi-surface restorations where other materials have a poor prognosis: molars must involve ≥4 surfaces and ≥2 cusps; bicuspids must involve ≥3 surfaces and ≥1 cusp; anterior teeth must involve ≥4 surfaces and ≥50% of the incisal edge.see structural thresholds
Crown build-up procedures are allowed when necessary for retention.
Post-endodontic crown criteria: When a crown follows root canal therapy: at least one month must have passed since therapy completion; include a dated post-endodontic radiograph; root filling must be within 2 mm of the radiographic apex unless anatomy limits it; filling properly condensed/obturated; tooth must oppose a crown/denture or be a partial denture abutment; patient must be free from active advanced periodontal disease.>=1 month
The fee for crowns includes the temporary crown; pre-fabricated or cast post and core allowed when clinically necessary for retention.
Removable prosthodontic services (partials and complete dentures) are covered when ALL of the following are met.
Indication and patient status: Prosthetic services must restore form/function due to premature loss of permanent teeth that would cause significant occlusal dysfunction. Partial dentures are covered only for recipients with good oral hygiene and periodontal health (AAP Type I or II) and a favorable prognosis.clinical judgement
Dentists should instruct patients in prosthesis care.
Radiographic and abutment requirements: Appropriate radiographs must show no untreated cavities or active periodontal disease in abutment teeth; abutments must have ≥50% bone support. A pre-existing removable prosthesis must be at least 5 years old and unserviceable to qualify for replacement.>=50% bone support; pre-existing prosthesis >= 5 years
Approval for certain partials (posterior/anterior) limited by remaining healthy teeth counts.
inv-07: Endodontic (Root Canal) Coverage Criteria — indications and exclusions
Root canal therapy (endodontics) is covered when ALL of the following technical and clinical criteria are met.
Clinical indication: Root canal therapy is performed to maintain teeth damaged through trauma or carious exposure and is indicated when clinically necessary to preserve the tooth.clinical indication
In most cases no prior authorization is required but a dated post-operative radiograph must be submitted for retrospective review.
Technical radiographic standards: Root filling must be within two millimeters of the radiographic apex unless canal curvature or calcification prevents it; the fill must be properly condensed/obturated and must not extend beyond the apex.within 2 mm of apex unless limited
Non-FDA accepted filling materials (e.g., Sargenti) are not covered.
Exclusions: Root canal therapy is not covered when gross periapical or periodontal pathosis demonstrates non-restorability, when the general oral condition does not justify RCT due to loss of arch integrity, for third molars unless they are abutments for partial dentures, when tooth demonstrates <50% bone support, when performed in anticipation of an overdenture, or when non-FDA accepted materials are used.
inv-08: Non-Restorable Tooth Determination — ANY of the listed conditions
A tooth may be deemed non-restorable if ANY of the following findings are present.
Non-restorable criteria: >75% clinical crown loss OR <50% bone support OR subosseous and/or furcation caries OR primary tooth with imminent exfoliation OR tooth apex surrounded by severe pathologic bone destruction.see text
Overall dental condition may favor an alternative treatment plan.
inv-09: Radiographic Examination and Reimbursement Criteria — quality and frequency standards
Radiographic examinations are reimbursed when they meet quality and frequency standards and follow the specified age- and risk‑based intervals.
Quality standards and reimbursement: Reimbursement includes exposure, developing, mounting and interpretation. Radiographs must meet readability quality standards; if not, DentaQuest may require re-taking at no additional cost and may recoup reimbursement for inadequate services.quality standards
Multiple x-rays of the same tooth/area may be denied if redundant or excessive.
Age- and risk-based frequency: Radiographic series and recall intervals vary by dentition status and caries risk (examples include posterior bitewings for primary dentition; recall intervals from 6–36 months depending on age and caries risk). No radiographs are indicated for edentulous recall visits without signs/symptoms.age-specific intervals
See Radiographic Criteria Exhibit for details.
Reimbursement scope:
inv-10: Bone Tissue Excision (Exostoses Removal) Authorization Criteria — documentation and indications
Removal of exostoses (tori) may be compensable when submitted with appropriate documentation and justification.
Documentation required for consideration: Submit appropriate radiographs (bitewings, periapical or panorex) and/or intraoral photographs or bone scans clearly identifying the exostoses, a treatment plan that includes the prosthetic plan if applicable, and a narrative of medical necessity when appropriate.document submission
Determinations are made by the dental specialist/Consultant; codes related to exostoses removal are subject to prior authorization.
inv-11: Denture Benefit Limits — frequency, relines, repairs, and inclusion of follow-up
Denture benefit limits include eligibility, included follow-up care, and frequency limitations after the initial period.
Replacement eligibility: A pre-existing removable prosthesis must be at least 5 years old and unserviceable to qualify for replacement. Replacement of lost or broken dentures less than 5 years of age is not a covered benefit.>=5 years
Preformed dentures with teeth already mounted are not covered.
Post-insertion follow-up care included: The fee for complete and partial dentures includes six months of post-insertion follow-up care including adjustments, repairs and relines.6 months
After six months: adjustments = 1 per calendar year; repairs = 2 per denture per year (max 5 per 5 years); relines = once per denture every 36 months.
Billing and service timing: All prosthetic appliances are inserted and adjusted before claim submission. Dentists must list the date final impressions were taken as the date of service; recipients must be eligible on that date for coverage.
Nitrous oxide requests are authorized when ANY of the following extensive-procedure or patient‑specific conditions apply.
Procedure-based indications: Extensive/complex procedures such as: four or more simple and/or surgical extractions; impacted wisdom teeth; surgical root recovery from the maxillary antrum; surgical exposure of impacted or unerupted cuspids; radical excision of lesions >1.25 cm.see text
Referencing AAOMS and ADA guidance.
Patient condition indications: Medical conditions such as cerebral palsy, epilepsy, intellectual disability (including Down's syndrome), documented failed local anesthetic or severe periapical infection, acute situational anxiety, and young patients with extensive procedures (age thresholds: <9 years = ≥6 teeth extensive; <6 years = ≥4 teeth extensive; <3 years automatically qualify).age-based and condition-specific
Patients less than 3 years qualify automatically.
inv-13: General Anesthesia and IV Sedation Authorization — scenarios and documentation expectations
General anesthesia or IV sedation is authorized when ANY of the following procedural or medical conditions are present; documentation is required.
Procedure-based indications: Extensive or complex oral surgical procedures such as four or more extractions in more than one quadrant in one appointment; impacted wisdom teeth; surgical root recovery from maxillary antrum; surgical exposure of impacted/unerupted cuspids; radical excision >1.25 cm.see text
Codes per ADA CDT.
Medical-condition indications: Medical conditions requiring monitoring (e.g., significant cardiac problems, severe hypertension) or underlying complex conditions (cerebral palsy, epilepsy, intellectual disability), documented failed sedation/local anesthesia, or patients ≤3 years old with extensive procedures.age and condition specific
Treatment plan and narrative of medical necessity required; emergency cases require retrospective documentation.
inv-14: Orthodontic Coverage (Salzmann Index) — Salzmann criteria and age thresholds
Comprehensive orthodontic services using the Salzmann Index are covered when ALL of the following are satisfied and prior authorization is obtained.
Prior authorization and documentation: All orthodontic services require prior authorization by a DentaQuest Dental Consultant and submission of a completed ADA claim form, occludable trimmed study models (cast or electronic) and a treatment plan; models must be intact and diagnostic.prior authorization required
Non-diagnostic or defective models may result in denied benefit.
Age and clinical indication: Orthodontic treatment is authorized only for handicapping malocclusion causing speech, eating/mastication, or psychological problems and is allowed for individuals age 20 and younger who meet Salzmann Index criteria. Treatment begun prior to age 21 may continue through completion even if the patient ages beyond 20 during treatment.<=20 years at treatment start
State or Plan establishes total score requirement.
inv-15: Orthodontic Coverage (HLD Index) — HLD index requirements
When required by State or Plan, the HLD Index is used to determine orthodontic medical necessity; all conditions below must be met.
Use and documentation: As required, the Handicapping Lingual-Labial Deviation (HLD) Index is used; submissions must include a completed ADA claim form, trimmed occludable study models (cast or electronic), and a treatment plan; models must be intact and diagnostic.varies by State/Plan
Orthodontic services considered for recipients with permanent dentitions (at least 1/2 to 3/4 of clinical crown exposed).
Authorization timing: Treatment must not begin prior to notification from DentaQuest indicating coverage or noncoverage; providers who begin treatment before authorization may be financially responsible or face termination of Provider Agreement.prior authorization required before starting treatment
Pre-service review for onlays requires specific radiographic documentation.
Radiographic prerequisites: Provide a periapical radiograph showing the full tooth length (clinical crown through apex) plus a panorex or, at minimum, four bitewing radiographs clearly showing adjacent and opposing teeth for pre-service review.periapical + panorex or >=4 bitewings
Treatment without necessary pre-service review is subject to retrospective review.
inv-17: Onlay Coverage Criteria (including post-endodontic) — all required conditions
Onlay coverage (including when placed after endodontic therapy) is allowed when ALL of the following criteria are satisfied.
General indication: Onlays are allowed only for teeth requiring multi-surface restorations where amalgams and other materials have a poor prognosis.
Molar threshold: Molars must have pathologic destruction involving four or more surfaces and two or more cusps to qualify for an onlay.
Bicuspids threshold: Bicuspids must have pathologic destruction involving three or more surfaces and at least one cusp to qualify for an onlay.
Build-up exclusion: Build-up procedures are not allowed in conjunction with onlays.
inv-18: Veneer Coverage Criteria (including post-endodontic) — all required conditions
Veneer coverage (including following endodontic therapy) is allowed when ALL of the following criteria are met.
General indication: Veneers are allowed only for anterior teeth requiring multi-surface restorations where amalgams and other materials have a poor prognosis.
Anterior tooth threshold: Anterior teeth must have pathologic destruction involving four or more surfaces and at least 50% of the incisal edge to qualify for a veneer.>=50% incisal edge
Build-up exclusion: Build-up procedures are not allowed in conjunction with veneers.
Post-endodontic veneer criteria: If the veneer follows root canal therapy: at least one month must have passed since completion; include a dated post-endodontic radiograph; the tooth must be filled within two millimeters of the radiological apex unless anatomy limits it; the filling must be properly condensed/obturated; the tooth must oppose a crown or denture or be an abutment for a partial denture; patient must be free from active advanced periodontal disease.
The policy excludes routine removal of teeth that are asymptomatic or disease-free. Specifically, prophylactic removal of asymptomatic teeth (including disease-free third molars) is not a covered benefit, and the removal of primary teeth whose exfoliation is imminent is likewise not covered. Documentation submitted for extractions should include appropriate radiographs and a narrative of medical necessity; treatments rendered without required pre-authorization are subject to retrospective review.
Root canal therapy is not covered when the tooth is determined to be non-restorable or when the patient’s overall oral condition does not justify endodontic treatment. Examples listed include gross periapical or periodontal pathosis (caries subcrestal or to the furcation), situations resulting in loss of arch integrity that justify not performing RCT, third molars (unless serving as a partial denture abutment), and teeth that demonstrate <50% bone support. Non‑FDA‑accepted filling materials (e.g., Sargenti) are also not covered.
Replacement or fabrication of removable prostheses is not covered under several conditions. A prosthesis will not meet coverage if a pre-existing prosthesis is less than 5 years old and still serviceable, if the patient lacks good oral and periodontal health or has untreated caries in abutment teeth, if abutment teeth have <50% bone support, or if there are eight or more posterior teeth in occlusion. Additional exclusions include recipients unable to accommodate or maintain a prosthesis, documented history of inability to wear a prosthesis, conversion of a partial to a complete denture when the partial is <5 years old, and situations where extensive repairs to a marginally functional partial are performed instead of fabricating a new prosthesis.
Preformed or stock dentures with teeth already mounted prior to the initial impression are explicitly excluded. The policy states that preformed dentures with teeth set in acrylic before the initial impression are not a covered benefit and cannot be used for fabrication of a new denture.
A new prosthesis is not compensable when provided within 24 months of a reline or repair of the existing prosthesis unless adequate documentation demonstrates that all possible procedures to render the existing denture serviceable have been exhausted.
Build-up procedures are not allowed in conjunction with onlays or veneers. The policy explicitly states that build-up procedures are not permitted when submitting requests for onlays (Exhibit S) or veneers (Exhibit T).
Submissions for periodontal scaling and root planing (codes D4341/D4342) require evidence of true attachment loss. Per the American Academy of Periodontology guidance adopted here, these therapeutic codes are appropriate only when there is loss of clinical attachment (typically probing depths and attachment loss usually >4 mm) and radiographic bone loss. If no attachment loss is present, root planing cannot be accomplished and submission of D4341/D4342 is not appropriate. Pre-operative periodontal charting and appropriate radiographs may be requested.
The policy lists additional non-compensable situations for removable prostheses and replacements. These include replacement of lost, stolen, or broken dentures that are less than 5 years old, use of preformed dentures with teeth already mounted, inadequate oral/periodontal health or untreated cavities in abutments, abutment teeth with <50% bone support, the presence of eight or more posterior teeth in occlusion, inability of the recipient to maintain or wear the prosthesis, and converting a recent partial denture to a complete denture rather than providing the appropriate appliance.
Orthodontic treatment is not authorized for purely cosmetic or aesthetic reasons. Comprehensive orthodontic services are only considered when they address handicapping malocclusion causing functional or psychological problems and, per the Salzmann Index criteria, are generally limited to individuals who meet the established scoring thresholds and are age 20 years or younger at the start of treatment.
Coding
Referenced CDT CodesCPT
D4341
Periodontal scaling and root planing — per quadrant
D4342
Periodontal scaling and root planing — other than full mouth, per quadrant
D1110
Prophylaxis - adult
D1120
Prophylaxis - child
D4346
Full mouth debridement to enable comprehensive exam and diagnosis
D4355
Full mouth debridement to enable evaluation and diagnosis
D7310
Alveoloplasty in conjunction with a surgical extraction in the same quadrant (not covered when performed in conjunction)
D7220
Removal of impacted tooth - soft tissue
D7230
Removal of impacted tooth - partially bony
D7240
Removal of impacted tooth - completely bony
1–10 of 11
1/2
General coding adherencemixed
See ADA CDT
DentaQuest adheres to code definitions as described in the American Dental Association Current Dental Terminology User's Manual
Code guidancemixed
See ADA CDT
DentaQuest adheres to the code definitions as described in the American Dental Association Current Dental Terminology User's Manual
Coding guidancemixed
No codes listed
inv-32: Attachment loss for scaling and root planing — threshold value
Attachment loss threshold> 4 mm (probing depths usually >4 mm and evidence of attachment loss required for D4341/D4342)
Radiographic/clinical supportLoss of clinical attachment must be demonstrated, typically with radiographic bone loss or periodontal charting.
Exclusion if absentIf there is no attachment loss, root planing cannot be accomplished and D4341/D4342 should not be submitted for payment.
inv-33: Tooth structural thresholds — surface and cusp requirements by tooth type
Molar thresholdPathologic destruction involving four or more surfaces and two or more cusps (required for crowns and onlays)
Provider Actions and Documentation Requirements
Prior Authorization
SPU pre-authorization required
All Short Procedure Units (SPU) cases must be pre-authorized. A narrative and documentation (radiographs, etc.) demonstrating need must be provided for consideration.
Prior Authorization
Prior authorization for impacted third molars
Extraction of impacted third molars requires prior authorization; benefit decisions are based on medical necessity and appropriate ADA codes (D7220, D7230, D7240, D7241). Prophylactic removal of disease-free third molars is not covered.
Prior Authorization
Pre-authorization requirement for prosthetics, exostoses, crowns, extractions
Certain prosthetic services, exostoses removal, crowns, and some extractions require prior authorization; supporting radiographs and a treatment plan must be submitted and treatment without authorization may be retrospectively reviewed.
Definitions
inv-70: Sources for guideline development — source organizations and references used to develop guidelines
Medicare and State MedicaidGuidelines are developed from Medicare and State Medicaid guidelines.
Professional societiesProfessional societies referenced include AAPD, American Endodontic Society, Academy of General Dentistry, American Orthodontic Society, AAOMS, among others.
Coding manuals and NCCISource materials include ADA CDT and CPT manuals and the National Correct Coding Initiatives.
inv-71: ASA Class III/IV — ASA classifications described
ASA Class IIIPatients with uncontrolled disease or significant systemic disease (e.g., poorly controlled hypertension, poorly controlled diabetes, arrhythmia, recent MI or stroke).
ASA Class IV
Background
This policy frames DentaQuest’s utilization management process by specifying how clinical criteria and guidelines are developed, reviewed, and applied to coverage decisions. Guidelines are drawn from external standards (Medicare/State Medicaid, ADA/CDT, specialty societies) and evaluated by internal committees including subject matter experts. New and emerging technologies are reviewed by the Peer Review Committee and a written opinion is provided within 45 days; accepted technologies are incorporated into clinical guidelines and, when required, submitted for final Plan approval. The policy establishes the expectations for documentation, prior authorization, and committee oversight used to ensure consistent, evidence‑based determinations.
Revision History
2018-05-01effective_date
Policy UM01-INS became effective.
2018-09-20last_reviewLatest
Policy UM01-INS underwent last review and revision on this date.
Policy Summary
Payerdentaquestdental
PolicyEstablishment and Adoption of Utilization Review Criteria and Clinical Guidelines
Policy CodePolicy UM01-INS
Change TypeNo material changes
Effective DateMay 1, 2018
Last ReviewSep 20, 2018
Next Review Date
Key ActionObtain prior authorization and provide required radiographs and a medical necessity narrative for services that require pre-authorization (for example, SPU cases, impacted third molar extractions, prosthetic services, nitrous oxide, general anesthesia, and orthodontics).
All periodontal procedures include routine postoperative care and local anesthesia.
Component services exclusion: If prophylaxis (D1110/D1120), full mouth scaling (D4346) or gross debridement (D4355) are submitted on the same date as scaling and root planing, they are considered components and not separately payable.
Alveoloplasty and orthodontic limitations: Alveoloplasty (D7310) in conjunction with a surgical extraction in the same quadrant is not covered. Extractions as part of orthodontic treatment are covered only if the orthodontic case itself is covered.
Authorization-required extraction types: Authorization is required for impacted wisdom teeth, residual roots requiring surgical removal, and surgical extraction of erupted teeth. Impacted third molars without complete root formation, without pathology, without aberrant position beyond normal variation, with only normal eruption discomfort/localized inflammation, or due to lack of eruptive space do not qualify for authorization.
Benefit decisions for impacted third molars are based on medical necessity and appropriate ADA codes (D7220, D7230, D7240, D7241).
Service limits and billing requirements:
The fee for complete and partial dentures includes six months of post-insertion follow-up care (adjustments, repairs, relines). After six months: adjustments = one per calendar year; repairs = two per denture per year (maximum five per five years); relines = once per denture every 36 months. When billing, list the date final impressions were taken as the date of service; recipient must be eligible on that date.
6 months included; relines once per 36 months; repairs 2/year (5/5 years)
Replacement of lost/broken dentures <5 years old is not covered; preformed dentures with teeth already mounted are not covered.
DentaQuest may require redo of inadequate root canal therapy at no additional cost and may recoup payments.
Reimbursement covers image acquisition plus processing and interpretation; excessive or redundant imaging may be denied in accordance with federal radiation exposure guidelines.
DentaQuest follows Department of Health and Human Services/FD A guidance for radiation exposure.
eligibility on impression date
A new prosthesis is not compensable within 24 months of a reline or repair of the existing prosthesis.
Scoring method:
DentaQuest uses a Modified Salzmann Index (weighted point system) assigning 2 points for each maxillary anterior tooth affected and 1 point for each mandibular incisor and posterior tooth affected, with additional points for crowding, rotation, spacing, overjet/overbite, cross-bite, open-bite and other deviations; a total qualifying score is set by the State or Plan.
score per State/Plan
Assessment may be made from casts or direct mouth assessment.
Post-endodontic onlay criteria:
If the onlay follows root canal therapy: at least one month must have passed since completion; include a dated post-endodontic radiograph; the tooth must be filled within two millimeters of the radiographic apex unless anatomy limits it; the filling must be properly condensed/obturated; the tooth must oppose a crown or denture or be an abutment for a partial denture; patient must be free from active advanced periodontal disease; the fee includes the temporary restoration.
>=1 month
Periodontal health requirement: Patient must be free from active and advanced periodontal disease for onlay coverage.
>=1 month
Fee for veneers includes the temporary restoration.
Periodontal health requirement: Patient must be free from active and advanced periodontal disease for veneer coverage.
Bicuspid (premolar) thresholdPathologic destruction involving three or more surfaces and at least one cusp (required for crowns and onlays)
Anterior tooth thresholdPathologic destruction involving four or more surfaces and at least 50% of the incisal edge (required for crowns and veneers)
inv-34: Post-endodontic timing — wait >=1 month before crown
Minimum wait timeOne month must have passed since root canal therapy completion before requesting a crown, onlay, or veneer following endodontic therapy.
Required radiographRequest must include a dated post-endodontic radiograph for crowns, onlays, and veneers following root canal therapy.
Endodontic fill standardTooth must be filled within two millimeters of the radiological apex unless anatomy prevents; filling must be properly condensed/obturated.
inv-35: Extractions triggering anesthesia/nitrous oxide — 4 or more extractions in one appointment
Extraction count triggerFour (4) or more simple and/or surgical extractions in one appointment (often in more than one quadrant) commonly trigger authorization for nitrous oxide or general anesthesia.
Related surgical triggersImpacted wisdom teeth, surgical root recovery from maxillary antrum, and surgical exposure of impacted/unerupted cuspids are also listed as indications.
Documentation requirementWhen authorized, narrative and supporting documentation are required; emergency procedures require retrospective submission if prior authorization not possible.
Patients <9 yearsMust have 6 or more teeth with extensive procedures to be considered for nitrous oxide authorization.
Patients <6 yearsMust have 4 or more teeth with extensive procedures to be considered for nitrous oxide authorization.
Patients <3 yearsPatients less than 3 years old automatically qualify for consideration for nitrous oxide/general anesthesia with extensive procedures.
inv-37: Prosthesis replacement eligibility — existing prosthesis must be >=5 years and unserviceable
Minimum age of existing prosthesisPre-existing prosthesis must be at least 5 years old to qualify for replacement.
Serviceability requirementThe existing prosthesis must be unserviceable to qualify for replacement.
Exclusion for newer prosthesesReplacement of lost or broken dentures less than 5 years of age is not a covered benefit.
inv-38: Radiographic requirement — periapical showing full tooth length and panorex or >=4 bitewings
Periapical view requirementProvide a periapical x‑ray showing full tooth length (clinical crown through the apex) for pre-service review.
Alternate seriesA panorex (panoramic) radiograph may be submitted instead of bitewings, or at minimum four bitewings showing adjacent and opposing teeth.
Use casesRequired for crown, onlay, veneer, extraction, and prosthetic pre-authorization submissions as specified.
Prior Authorization
Prior authorization when clinical criteria met (anesthesia, nitrous, orthodontics)
Prior authorization is required for nitrous oxide, general anesthesia/IV sedation, and orthodontic services in most cases; documentation and clinical criteria must be met for approval.
Prior Authorization
Orthodontic prior authorization required before treatment begins
All orthodontic services require prior authorization by a DentaQuest Dental Consultant; treatment must not begin before notification of coverage or noncoverage.
Submitted documentation must include a completed ADA claim form, occludable trimmed study models (cast or electronic), and a treatment plan.
Models must be intact and diagnostic; non-diagnostic or defective models may result in denial.
Documentation Required
Pre-service radiographs may be required (periapical + panorex/4 bitewings)
Pre-service review may be required; submissions for authorization often must include a periapical x-ray showing full tooth length plus a panorex or at minimum four bitewings showing adjacent and opposing teeth.
Note
Obtain prior authorization and submit required documentation
Providers must obtain necessary prior authorizations and submit required documentation (radiographs, narratives, treatment plans) for procedures that the policy identifies as requiring review; failure to do so can trigger retrospective review.
Include detailed treatment plan and sufficient radiographs (bitewings, periapicals or panorex) when requested.
Treatment rendered without necessary pre-authorization is subject to retrospective review.
Denial Risk
Quality-driven remediation for endodontics
If a root canal filling does not meet DentaQuest treatment standards, DentaQuest may require the procedure be redone at no additional cost and may recoup prior reimbursement.
Billing Rule
Denture follow-up services included in initial fee (first 6 months)
The fee for complete and partial dentures includes six months of post-insertion follow-up care; adjustments, repairs and relines during the first 6 months are included and not billed separately.
After 6 months: adjustments = one per calendar year; repairs = two per denture per year (max five per 5 years); relines = once every 36 months.
Note
Follow authorization and documentation requirements
Providers must follow prior-authorization and documentation rules listed elsewhere in the policy when submitting requests for review; missing documentation may lead to retrospective review or denial.
Documentation Required
SPU narrative and documentation required for pre-authorization
For SPU consideration, submit a detailed narrative and supporting documentation (radiographs, etc.) demonstrating medical necessity and why hospitalization or SPU is required.
Narrative must describe why in-office treatment is not appropriate and justify hospitalization when applicable.
Documentation Required
Extraction pre-authorization requires mounted diagnostic radiographs with patient identifiers
Pre-authorization for extractions requires diagnostic-quality periapical and/or panoramic radiographs that are mounted and contain the patient name and date the radiographs were taken; duplicate radiographs must be labeled R/L when applicable.
Documentation Required
Crown pre-authorization requires panorex or ≥4 bitewings
Crown pre-authorization requires a panorex or, at minimum, four bitewing radiographs clearly showing adjacent and opposing teeth.
Documentation Required
Periodontal pre-op radiographs, charting, and detailed treatment plan required
For periodontal procedures, providers may be required to submit pre-operative radiographs (full mouth preferred), periodontal charting dated within 12 months, and a detailed treatment plan.
Documentation Required
Include panorex or ≥4 bitewings plus treatment plan for pre-authorization
Pre-authorization submissions must include appropriate radiographs (panorex or at minimum four bitewings; bitewings, periapicals or panorex) and a detailed treatment plan when requested.
Documentation Required
Post-endodontic documentation required for crowns
When requesting crowns after endodontic therapy, include a dated post-endodontic radiograph and documentation that at least one month has passed since completion of root canal therapy.
Documentation Required
Bone excision (exostoses) documentation required for prior authorization
For exostoses removal (bone excision) prior authorization may require appropriate radiographs and/or intraoral photographs, a treatment plan including the prosthetic plan, and a narrative of medical necessity if appropriate.
Documentation Required
Treatment plan and medical necessity narrative required for anesthesia/nitrous/onlay review
Submit a treatment plan and narrative describing medical necessity when requesting nitrous oxide, general anesthesia/IV sedation, or onlay pre-service review; if performed emergently without prior authorization, submit the same documentation for retrospective review.
Documentation Required
Orthodontic supporting documentation (ADA form, study models, treatment plan)
Orthodontic prior authorization requests must include a completed ADA claim form, occludable trimmed study models (cast or electronic) and a treatment plan; models must be intact and diagnostic.
Billing Rule
Denture date of service = date final impressions taken; recipient must be eligible
When billing for partial and complete dentures, list the date the final impressions were taken as the date of service; the recipient must be eligible on that date for the denture service to be covered.
Documentation Required
Onlay radiographs required (periapical full tooth length + panorex or ≥4 bitewings)
Onlay pre-treatment documentation must include a periapical radiograph showing the full length of the tooth (clinical crown through apex) plus a panorex or at minimum four bitewings showing adjacent and opposing teeth.
Documentation Required
Required radiographic documentation for pre-service review
For pre-service review provide a periapical x-ray showing full tooth length including crown through the apex, and a panorex or at minimum four bitewing radiographs showing adjacent and opposing teeth.
Documentation Required
Include dated post-endodontic radiograph for onlay/veneer after RCT
When requesting an onlay or veneer following root canal therapy, include a dated post-endodontic radiograph with the pre-authorization and confirm at least one month has passed since therapy completion.
Denial Risk
Retrospective review risk when pre-authorization missing
Treatments rendered without required pre-authorization or pre-service review are subject to retrospective review and may affect payment or require submission of documentation for payment determination.
Emergency procedures performed without prior authorization require retrospective submission of the same documentation (radiographs, narratives, treatment plan).
Prior Authorization
SPU and certain extractions require prior authorization with radiographs and narrative
Short Procedure Units (SPU) and specified extractions (impacted wisdom teeth, residual roots, surgical extractions) require prior authorization; submit diagnostic radiographs, mounting with patient identifiers, and narrative of medical necessity.
Denial Risk
Radiograph redundancy may lead to denial
Multiple x-rays of the same tooth or area may be denied if DentaQuest determines the number to be redundant, excessive, or not consistent with federal radiation exposure guidelines.
Denial Risk
Lack of required pre-authorization may trigger retrospective review and affect payment
Treatment rendered without necessary pre-authorization is subject to retrospective review and may affect payment.
Denial Risk
Ensure orthodontic study models are diagnostic or risk denial
Non-diagnostic or defective orthodontic study models may result in a denied benefit decision; ensure models are intact, occludable and diagnostic before submission.
Denial Risk
Denture replacements <5 years not covered
Replacement of lost or broken dentures that are less than five years old is not a covered benefit and may be denied.
Denial Risk
Risk of retrospective review for missing pre-service review
Treatment rendered without necessary pre-service review is subject to retrospective review.
Patients with severe systemic disease that is a constant threat to life and may require hospitalization for dental procedures.
Use in authorizationASA III/IV classification is used as an indication for Short Procedure Units (SPU) and pre-authorization consideration.
inv-72: Prosthetic services / Denture initial placement — definition of initial placement and eligibility
Initial placement definitionA denture is considered initial placement if the patient has never worn a prosthesis.
Partial denture eligibilityPartial dentures covered only for recipients with good oral hygiene, good periodontal health (AAP Type I or II), and a favorable prognosis.
Documentation expectedDetailed treatment plan and appropriate radiographs showing adjacent and opposing teeth must be submitted for authorization review.
inv-73: Non-restorable tooth — definition and criteria (>75% crown loss, <50% bone support, etc.)
Clinical crown loss>75% loss of the clinical crown is a criterion indicating a tooth may be non-restorable.
Bone supportLess than 50% bone support is a criterion indicating non-restorability.
Other criteriaSubosseous and/or furcation caries, primary tooth with imminent exfoliation, or tooth apex surrounded by severe pathologic bone destruction also indicate non-restorability.
inv-74: Salzmann Index — description of weighted scoring system for orthodontic severity
PurposeA weighted scoring system used to assess orthodontic handicapping malocclusion severity for prior authorization decisions.
Scoring details2 points for each maxillary anterior tooth affected; 1 point for each mandibular incisor and all posterior teeth affected; additional points assigned for crowding, rotation, spacing, overjet/overbite, cross-bite, open-bite, and other deviations.
Age limit and useApplied for recipients age 20 and younger; total score requirements are established by State or Plan.
inv-75: HLD Index — description of Handicapping Lingual-Labial Deviation Index
PurposeHandicapping Lingual-Labial Deviation (HLD) Index used by some States or Plans to assess orthodontic benefit requests.
DocumentationRequires completed ADA claim form, occludable trimmed study models, and a treatment plan; models must be intact and diagnostic.
State/Plan variabilityTotal qualifying Index scores vary by State or Plan; use and qualifying threshold determined by local requirements.
inv-76: Onlay clinical thresholds — molar/bicuspid/anterior surface and cusp thresholds
Molar onlay thresholdMolars must have pathologic destruction involving four or more surfaces and two or more cusps to qualify for an onlay.
Bicuspids onlay thresholdBicuspids must have pathologic destruction involving three or more surfaces and at least one cusp to qualify for an onlay.
Build-up exclusionBuild-up procedures are not allowed in conjunction with onlays.
Anterior veneer thresholdAnterior teeth must have pathologic destruction involving four or more surfaces and at least 50% of the incisal edge to qualify for a veneer.
Build-up exclusionBuild-up procedures are not allowed in conjunction with veneers.
Post-endodontic timingIf following root canal therapy, at least one month must have passed and a dated post-endodontic radiograph included.