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DentaQuest Dental procedure code coverage and documentation/payment review requirements
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This document lists dental procedure codes with age/tooth limits, prior review requirements, and required documentation (narrative of medical necessity, pre/post-op x‑rays, models/images) governing prior authorization and payment review for providers submitting these codes to DentaQuest Dental.
Policy Summary
Payerdentaquestdental
PolicyDentaQuest Dental procedure code coverage and documentation/payment review requirements
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionProvide a narrative of medical necessity and required pre/post‑operative radiographs or imaging when submitting prior review or payment documentation for codes flagged as 'Review Required'.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
~150+procedure code entries shown in this partial extract
multipleentries requiring narrative of medical necessity
manyentries marked 'Yes' for review/prior authorization
3/1/2012frequently appearing policy reference date
Coverage Criteria by Procedure Code
inv-01: Coverage criteria by code
Coverage stance and required documentation for the listed CDT procedure codes.
D0210 — Review Required; narrative of medical necessity; pre-operative x-ray(s); age limitation 2-5; payment review effective 8/15/2016
D0270 — Review Required; narrative of medical necessity; pre-operative x-ray(s); payment review effective 8/15/2016
D0272 — Review Required; narrative of medical necessity; pre-operative x-ray(s); payment review effective 8/15/2016
D0273 — Review Required; narrative of medical necessity (pre-op x-rays listed); age limitation 1-9; payment review effective 8/15/2016
D0274 — Review Required; narrative of medical necessity; pre-operative x-ray(s); age limitation 1-9; payment review effective 8/15/2016
D0330 — Review Required; narrative of medical necessity; pre-operative x-ray(s); age limitation 3-5
D1352 — Review Required; narrative of medical necessity; age limitation 15-20; payment review effective 7/1/2017
D2510 — Review Required; narrative of medical necessity; pre- and post-operative x-ray(s); age limitation 13-20; payment review effective 3/1/2012
D3347 — Review Required; narrative of medical necessity; post-op x-ray(s); age limitation 6-20; specified tooth list; payment review effective 3/1/2012
D4240/D4249 — Review Required; full-mouth or post-operative x-rays and narrative of medical necessity; age limitations indicated where shown
D4342 — Requires narrative of medical necessity and pre/post-operative x-ray(s); payment review effective 1/1/2019
D5211 / Mandibular partial denture — Review Required; pre-operative x-ray(s) and narrative of medical necessity; payment review effective 3/1/2012
Overdentures and related removable prosthodontics — Coverage indicated Yes for many entries; require narrative of medical necessity and pre-operative x-ray(s); some entries have effective dates 1/1/2014
Connective tissue grafts and other periodontal graft procedures — Review Required; narrative of medical necessity and pre-operative x-ray(s); many entries show 'Yes' for review
Fixed prosthodontics (pontics, retainers, crowns) — Coverage contingent on pre- and/or post-operative x-rays and a narrative of medical necessity; age/tooth ranges specified per code
D6791 / D6792 / D6920 / D6999 — Crowns, connector bar, fixed prosthodontic procedures — require narrative and pre/post-op x-rays; many have payment review effective 3/1/2012
Extractions and impacted tooth removal (D7140-D7241) — Coverage indicated Yes; require narrative of medical necessity and pre-operative x-ray(s); some entries show payment review dates (e.g., 3/1/2012)
Maxillofacial/craniofacial prostheses (nasal septal, ocular, cranial, facial augment implant, auricular/orbital/auricular prostheses) — Coverage indicated Yes for many; require radiographs and narrative of medical necessity; payment review dates where shown
Miscellaneous accessories and devices (radiation cone locator, fluoride gel carrier, surgical/comissure splints, unspecified maxillofacial prosthesis) — Require pre-op/post-op x-rays and narrative of medical necessity where indicated; many entries list payment review date 3/1/2012
Prosthodontic fixed and removable items (pontics, retainers, crowns) — Many entries list Teeth 1-32 or specific tooth ranges and require pre/post-op x-rays plus narrative of medical necessity
Summary note: Many codes marked 'Yes' for Review Required indicate that coverage is conditioned on submission of a narrative of medical necessity and the specified radiographs (pre-op and/or post-op) as listed per code
inv-02: Per-code coverage and documentation criteria (partial)
Per-code coverage indicators and documentation expectations (partial list):
Various D-codes: Coverage flags vary (Yes or blank). Many codes marked 'Yes' require a narrative of medical necessity and pre- and/or post-operative radiographs as specified in each entry.
Prosthesis and maxillofacial devices: Nasal septal, ocular, auricular, orbital, cranial and facial prostheses and related devices commonly indicate 'Yes' for coverage and require radiographs and a narrative of medical necessity.
Fixed prosthodontics (pontics, retainers, crowns): Entries for pontics, retainers and crowns specify tooth ranges (often Teeth 1-32 or specific teeth), age limits and require pre- and/or post-operative x-rays plus a narrative of medical necessity.
Extractions and impacted tooth removals (D7140-D7241): These oral surgery codes are marked 'Yes' and commonly require a narrative of medical necessity and pre-operative x-rays; some entries include effective/review dates.
Orthodontic services (D8010-D8680): Orthodontic codes routinely list required supporting documentation such as models, panoramic and cephalometric radiographs (pano, cephalo), clinical photographs; some entries include age limits and payment review dates.
Anesthesia and sedation codes: Deep sedation/general anesthesia, intravenous and non-intravenous moderate (conscious) sedation entries require a narrative of medical necessity and, in some instances, pre-operative x-rays; time-based increments and effective dates are listed per entry.
Periodontal procedures and grafts: Periodontal scaling/root planing, connective tissue grafts and related periodontal procedures require full-mouth or specified x-rays, perio charting and a narrative of medical necessity; some entries show specific effective dates.
Prosthodontics accessories and adjuncts: Radiation cone locators, fluoride gel carriers, splints and similar accessories are frequently marked 'Yes' and require radiographs and a narrative of medical necessity; many show payment review dates.
Therapeutic injections and drugs: Therapeutic drug injections billed by report require a description of drugs with the claim; other drugs/medicaments may require narrative of medical necessity.
Occlusal appliances and analysis: Occlusal guard (hard appliance, full arch) and occlusion analysis-mounted cases indicate coverage contingent on submission of a narrative of medical necessity.
Miscellaneous note: Where entries list 'models, pano, cephalo, photos' or 'full mouth x-rays, perio charting & narrative' those items are required supporting documentation for coverage/review as specified per code.
Timing and effective dates: Multiple entries include payment review effective dates (examples: 3/1/2012, 7/1/2017, 1/1/2019, 8/15/2016); check each code entry for the applicable date.
Summary: This partial list illustrates the pattern: covered codes frequently require a narrative of medical necessity plus the radiographs or supporting records specified in the table entry to be eligible for payment review/authorization.
inv-03: Documentation-conditioned coverage criteria
Coverage for the listed services is conditioned on the specific documentation elements noted per entry.
Orthodontic services (e.g., D8670, D8680) — models, panoramic and cephalometric radiographs, clinical photographs are required; age limits noted (e.g., 0-20) where specified.
Local anesthesia not provided in conjunction with operative or surgical procedures — coverage requires a narrative of medical necessity (per table entries).
Deep sedation / general anesthesia (first 15 minutes and subsequent 15-minute increments) — coverage requires a narrative of medical necessity and, for some increments, pre-operative x-rays as indicated; time increments and effective dates are listed per entry.
Intravenous and non-intravenous moderate (conscious) sedation — coverage requires a narrative of medical necessity and, in some instances, pre-operative x-rays; effective dates are shown per entry.
Therapeutic drug injections and other drugs/medicaments billed by report — require a description of drugs with the claim and/or a narrative of medical necessity as specified.
Behavior management and treatment-of-complication entries billed by report — require a narrative of medical necessity.
Occlusal guard (hard appliance, full arch) and occlusion analysis-mounted cases — coverage contingent on a narrative of medical necessity.
Operational note: For any service entry that lists specific supporting items (models, pano, cephalo, photos, full mouth x-rays, perio charting), providers must submit those documents with the narrative of medical necessity to satisfy the documentation-conditioned coverage criteria.
Procedure Codes and Code Groups
Sample covered CDT codes with documentation/review notesCPT | mixedCovered
| D0210 | Intraoral complete series of radiographic images |
| D0274 | Bitewings - four radiographic images |
| D0330 | Panoramic radiographic image / Cone beam CT capture and interpretation |
| D2510 | Inlay - metallic - 1 surface |
| D3347 | Retreatment of previous root canal therapy - molar (example entry) |
| D4240 | Gingival flap procedure including root planing - one to three contiguous teeth per quadrant |
| D5211 | Mandibular partial denture - resin base |
Prosthesis and related codesmixedCovered
| D5936 | Obturator prosthesis, interim |
| D5937 | Trismus appliance (not for TMD treatment) |
| D5951 | (listed) - entries include necessity and radiographs |
| D5958 | Palatal lift prosthesis, interim |
| D5959 | Palatal lift prosthesis, modification |
| D5960 | Speech aid prosthesis, modification |
Fixed prosthodontics and crownsmixedCovered
| pontic-cast base metal | pontic, various materials |
| retainer - cast metal fixed | fixed retainer, requires pre/post-op x-rays |
| crown-resin with base metal | resin crown with base metal |
| D6791 | Crown - full cast base metal |
| D6792 | Crown - full cast noble metal |
Extractions and impacted tooth removalCPTCovered
| D7140 | Extraction, erupted tooth or exposed root |
| D7210 | Extraction with elevation of mucoperiosteal flap if indicated |
| D7220 | Removal of impacted tooth - soft tissue |
| D7230 | Removal of impacted tooth - partially bony |
| D7240 | Removal of impacted tooth - completely bony |
| D7241 | With unusual surgical complications |
Orthodontic procedure codesCPTCovered
| D8670 | Periodic orthodontic treatment visit |
| D8680 | Orthodontic retention (removal of appliances) |
Age limits present on entries
Examples of age limits shownD0210: 2-5; D0330: 3-5; D1352: 15-20; multiple restorative/onlay/inlay codes (D2510, D2543, D2544, D2650, D2651) list 13-20.
Orthodontic age range exampleD8670 and D8680 list age limit 0-20.
Crown/prosthodontic age examplesMany crown and pontic entries list 16-20 (e.g., pontic, crown series).
Tooth range examples
Full adult dentition rangeTeeth 1 - 32 is used for many prosthodontic and crown entries (e.g., pontics, retainers, crowns).
Specific tooth ranges in crownsD6791/D6792 list Teeth 1-5, 12-21, 28-32 for full-cast crowns.
Arch or limited rangesSome fixed prosthodontic procedures list Per Arch or limited tooth groups (examples in D6920 and related entries).
Age limit for certain orthodontic services
Orthodontic age limit (example)D8670 and D8680: age limit 0-20 for periodic orthodontic visits and retention.
Supporting docsThese orthodontic entries require models, panoramic and cephalometric radiographs, and photos.
Coverage flagBoth D8670 and D8680 are marked Yes for review/coverage with documentation.
Provider Documentation, Prior Review, and Billing Actions
Prior Authorization
Radiographs — prior review and documentation
These radiographic procedure codes are flagged 'Review Required' and must be accompanied by documentation of medical necessity plus pre‑operative radiographs (narrative of medical necessity).
- Codes called out include D0210, D0270, D0272, D0273, D0274, D0330.
- Documentation required column: 'necessity, pre‑op x‑ray(s) narr. of med.' (see grid).
Prior Authorization
Restorative/Sealant — prior review and documentation
Restorative and preventive codes marked 'Yes' for review require a narrative of medical necessity and pre‑ and/or post‑operative radiographs for payment review.
- Example codes: D1352 (sealant), D2510 (inlay), D2542–D2544, D2650–D2651.
- Entries list 'narr. of med. necessity' and 'pre and post‑op x‑ray(s)' where applicable.
Prior Authorization
Endodontics/Periodontics — prior review and documentation
Endodontic and periodontal procedure entries commonly require a narrative of medical necessity and post‑operative or full‑mouth radiographs; many of these entries are marked 'Yes' for review.
- Representative endodontic codes (retreatment, D3347, D3348, D3410) list 'post‑op x‑ray(s) narr. of med. necessity'.
- Periodontal codes (D4240, D4241, D4245, D4249, D4342) require full‑mouth or pre/post‑op x‑rays and narratives of medical necessity.
Documentation Required
Periodontal/Prosthodontic — documentation requirements
Periodontal debridement and removable prosthodontic entries require full‑mouth radiographs, periodontal charting, and a narrative of medical necessity; many entries note pre‑operative x‑rays.
- D4342 (full mouth debridement) and scaling/root plan entries list 'full mouth x‑rays, perio charting & narrative' and 'narr. of med. necessity, pre/post‑op x‑ray(s)'.
- Complete and immediate dentures, partials and overdentures list pre‑operative x‑rays and narratives of medical necessity where indicated.
Documentation Required
Maxillofacial/craniofacial prostheses
Maxillofacial and craniofacial prostheses are indicated as covered ('Yes') in the grid but require radiographs and a narrative of medical necessity to support the claim.
- Examples include nasal septal prosthesis, ocular prosthesis (interim), cranial prosthesis, and facial augment implant prosthesis — each lists 'necessity, pre‑op x‑ray(s)' or 'ray(s) narr. of med.'
- Many entries show a payment review effective date (e.g., 3/1/2012) alongside documentation requirements.
Documentation Required
Prosthodontics documentation requirements
Prosthodontic and accessory items frequently require pre‑ and/or post‑operative radiographs plus a narrative of medical necessity as listed in the coverage grid.
- Radiation cone locator, fluoride gel carrier, pontics, and fixed prosthodontic pontic entries list 'ray(s) narr. of med. necessity, pre‑op/post‑op x‑ray(s)'.
- Many prosthodontic codes include 'necessity, pre and post‑op x‑ray(s)' or similar wording in the documentation column.
Prior Authorization
Oral surgery authorization notes
Extraction and oral surgery procedure codes routinely marked 'Yes' require a narrative of medical necessity and pre‑operative radiographs; some entries also show payment review dates.
- Codes D7140, D7210, D7220, D7230, D7240, D7241 list 'necessity, pre‑op x‑ray(s) narr. of med.' or 'ray(s) narr. of med.' in the documentation field.
- Several surgical extraction entries include an effective/review date of 3/1/2012.
Documentation Required
Orthodontic visits and retention
Orthodontic periodic treatment visits (D8670) and retention (D8680) require supporting diagnostic records — models and panoramic/cephalometric radiographs and clinical photos — and are limited by the listed age ranges.
- D8670 and D8680 list 'models, pano, cephalo, photos' in the documentation column and age limit '0‑20'.
- Removable and fixed appliance therapy entries also require a narrative of medical necessity and similar documentation.
Documentation Required
Anesthesia and sedation documentation
Anesthesia and sedation services (including deep sedation/general anesthesia and moderate conscious sedation) require a narrative of medical necessity and, in some instances, pre‑operative radiographs; time‑increment codes note the narrative requirement.
- Local anesthesia not in conjunction with operative/surgical procedures is listed with 'Narrative of medical necessity'.
- Deep sedation/general anesthesia first and subsequent 15‑minute increments and intravenous/non‑intravenous moderate sedation entries specify 'narrative of medical necessity' and in some cases 'pre‑op x‑ray(s)'.
Documentation Required
Drug injection and behavior management documentation
Therapeutic drug injection claims must include a description of the drugs with the claim; other drug/medicament entries and behavior management require a narrative of medical necessity.
- Therapeutic drug injection entries state 'Description of drugs with claim.'
- Other drugs/medicaments (by report) and 'behavior management, by report' list 'narrative of medical necessity' in the documentation field.
Documentation Required
Occlusal appliances
Coverage for occlusal appliances (occlusal guard) and occlusion analysis is conditional on a narrative of medical necessity being submitted with the claim.
- Occlusal guard (hard appliance, full arch) and occlusion analysis‑mounted case are listed 'Yes' for coverage with 'narrative of medical necessity' required.
- Ensure the narrative documents the clinical need for the occlusal appliance or analysis.
Definitions and Quick Reference
Review Required
Definition'Review Required' indicates the procedure code is listed as requiring prior/payment review in the table.
Common examplesRadiographs (D0210, D0270–D0274, D0330), many restorative and surgical codes (e.g., D1352, D2510, D3347, D7140) are marked Yes for review.
Implication for providersWhen 'Review Required' = Yes, submit narrative of medical necessity and required radiographs as specified for payment review.
Narrative of medical necessity (provider-submitted explanation)
DefinitionNarrative of medical necessity: provider-submitted explanation supporting the clinical need for the procedure, often required with pre- and/or post-operative x-rays.
When requiredListed for radiographs (D0210, D0270–D0274, D0330), restorative, endodontic, periodontal, orthodontic, anesthesia and other entries.
PurposeUsed to justify coverage and support payment review or prior authorization decisions.
Narrative of medical necessity — written justification
Written justification requirementNarrative of medical necessity is explicitly required for coverage for many prosthodontic and restorative entries (e.g., D2510, D2543, D2544).
Often accompanied by imagesNarratives are commonly requested together with pre- and/or post-operative x-rays for payment review.
Payment review datesSeveral entries with this requirement include payment review effective dates (e.g., 3/1/2012, 7/1/2017).
Teeth 1 - 32
Teeth 1 - 32 meaning'Teeth 1 - 32' indicates applicability to any adult permanent tooth numbered 1 through 32 and is used on many prosthodontic and crown listings.
Used across entriesPontics, retainers, crowns, and fixed prosthodontic procedures frequently reference Teeth 1 - 32.
Specific listingsSome crowns list narrower sets too (e.g., D6791/D6792 list Teeth 1-5, 12-21, 28-32 in addition to broader ranges).
Deep sedation / general anesthesia entries
Time-based anesthesia codesDeep sedation/general anesthesia entries include a first 15-minute code and subsequent 15-minute increment codes; each lists narrative of medical necessity as required.
DocumentationSome anesthesia increments also require pre‑operative x‑rays in addition to the narrative of medical necessity.
Related sedation entriesIntravenous and non‑intravenous moderate (conscious) sedation entries likewise require narrative of medical necessity and, in some cases, pre‑op x‑rays.
Narrative of medical necessity — definition and usage
Definition and purposeNarrative of medical necessity: a provider’s written explanation describing clinical need and justification for the requested procedure to support coverage and payment review.
Where usedRequired for radiographs, restorative, endodontic, periodontal, prosthodontic, orthodontic, anesthesia, drug/medicament, and other by‑report entries across the grid.
Typical attachmentsOften submitted with pre‑ and/or post‑operative radiographs, models, or clinical photos as specified per code.
Diagnostic imaging and models for orthodontic entries
Orthodontic supporting itemsOrthodontic entries (e.g., D8670, D8680) require diagnostic models, panoramic radiograph (pano), cephalometric radiograph (cephalo), and clinical photographs.
Timing and examplesThese items are noted specifically for periodic orthodontic visits and retention and are part of documentation for coverage/payment review.
Models required for appliancesRemovable and fixed appliance therapy entries reference models in addition to imaging for medical necessity documentation.
Drug description required with claim
Other drug/medicament entriesOther drugs and/or medicaments (by report) are marked Yes and require a narrative of medical necessity.
Behavior management and complicationsBehavior management and treatment of post‑surgical complications by report require a narrative of medical necessity.
Policy Summary
Payerdentaquestdental
PolicyDentaQuest Dental procedure code coverage and documentation/payment review requirements
Policy CodePolicy N/A
Change TypeNo material change
Effective DateN/A
Next Review DateN/A
Key ActionProvide a narrative of medical necessity and required pre/post‑operative radiographs or imaging when submitting prior review or payment documentation for codes flagged as 'Review Required'.
SourceLink
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