CurrentFidelis CarePolicy N/A

Dental benefits — coverage criteria for CDT procedure codes, frequency limits, and provider requirements

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This document describes the Fidelis Care 2025 dental benefits package, listing covered dental procedure codes, frequency limits, and provider requirements for members of specific Fidelis/Wellcare plans (examples include several HMO D-SNP plans in NY). It affects providers submitting claims for covered dental services under the 2025 plan benefit package.

Policy Summary

PayerFidelis Care

PolicyDental benefits coverage criteria (CDT codes, frequency, prior authorization)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit required clinical documentation (including X-rays) for listed imaging, implant, and prosthetic procedures when indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025plan year

HMO D-SNP (NY)example plans

50%bone support threshold

60 mocommon crown interval

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CurrentFidelis CarePolicy N/A

Dental benefits — coverage criteria for CDT procedure codes, frequency limits, and provider requirements

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Know when Fidelis Care releases new policies or updates existing guidance.

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Policy Summary

PayerFidelis Care

PolicyDental benefits coverage criteria (CDT codes, frequency, prior authorization)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit required clinical documentation (including X-rays) for listed imaging, implant, and prosthetic procedures when indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025plan year

HMO D-SNP (NY)example plans

50%bone support threshold

60 mocommon crown interval

96 moimplant crown interval

select codesprior auth noted

Coverage Criteria and Limits

inv-01: Covered with code-specific criteria

Covered when code-specific frequency and condition rules are met as listed below:

Preventive/diagnostic coverage: Cover prophylaxis (D1110) one per 6 months; periodic evaluations (D0120) one per 6 months; comprehensive evaluation (D0150) one per lifetime; detailed evaluations (D0160) per 90 days as specified.per-code frequencies

See individual code lines for exact per-day/6mo/12mo/36mo/lifetime limits

Radiographic coverage: Cover intraoral and extraoral radiographic codes with specified frequency limits (e.g., D0210/D0330 per 36 months; D0220 up to three per 6 months; D0270–D0274 up to three per 12 months).per-code frequencies

Maximum numbers per day or per period apply; some codes limited when performed same day as others.

Imaging and advanced services: Advanced imaging (CBCT/CT and interpretation codes D0364–D0368) require prior authorization and are covered only under specified clinical indications (for example, implant planning or surgical necessity).prior authorization required

Documentation of clinical necessity and interpretation may be required

Tele-dentistry: D0391 (teledentistry asynchronous) is allowed only when billed together with diagnostic intraoral images (D0701–D0709) as specified.must be billed with D0701–D0709 when indicated

Pairing requirement for tele-dentistry

Provider-type restrictions: Certain diagnostic/operative services (e.g., D0470 diagnostic casts, D0474 surgical pathology, D0485 oral pathology lab services, D0502 other oral surgical diagnostics) are covered only when provided by appropriate specialists as noted.provider type as noted

See code descriptions for provider restrictions

inv-02: General coverage criteria for restorations and crowns

Covered when ALL of the following are met

Structural and etiologic criteria: Documentation must show loss of tooth structure due to disease or trauma and provide broad supporting documentation of tooth structure status for the proposed restoration or crown.

See required minimum support node

Minimum support: At least 50% remaining root/bone (resting bone) support must be present for eligibility where indicated.>=50%

Third molars excluded unless medically necessary

Frequency limits: Replacements are limited to specified intervals: many single-tooth restorations every 24 months; many crowns/major prostheses every 60 months (per same tooth) unless otherwise stated.24 months or 60 months depending on code

Applies per patient/same tooth

inv-03: Covered crown materials/types

Covered crown types when criteria met

Types/materials: Multiple crown materials and types (high noble metal, porcelain fused to metal, all-ceramic/porcelain, resin-based, metal alloys/titanium variations) are covered when the general eligibility and code-specific frequency/support requirements are satisfied.

Each crown D-code carries its own frequency and structural requirements; third molars excluded unless medically necessary

inv-04: Prosthetic / Crown Eligibility

Covered when ALL of the following are met

Prosthetic eligibility: Provider must document broad loss of tooth structure or need for reconstruction and demonstrate at least 50% resting bone support for the involved teeth when required by the code.>=50% resting bone support

Excludes third molars except when medically necessary; documentation of new necessity required for replacements

inv-05: Restoration Frequency Rules

Covered according to the following frequency limits

Inlays/Onlays (D2910–D2915): Limit to 1 of D2910–D2915 per tooth every 12 months; not covered within 6 months of delivery.1/12 months

D2920 (cemented porcelain/ceramic inlay/onlay): Limit to 1 of D2920 per tooth every 24 months; not covered within 12 months of delivery.1/24 months

Prefabricated/prosthetic crowns (D2928, D2931–D2933): Limit to 1 per tooth every 60 months.1/60 months

Third molars excluded unless medically necessary

inv-06: Endodontic / Lifetime-limited Procedures

Covered when ALL of the following are met

Endodontic services (selected codes): Many endodontic and related codes (examples include D3110, D3120, D3310–D3348 group) are limited to one per tooth per lifetime; clinical documentation must support necessity and meet any code-specific requirements such as minimum resting bone support when stated.1 per lifetime (per tooth) where stated

Specific codes list their own limits and support requirements

inv-07: Coverage criteria by procedure group

Coverage limited by per-tooth/per-quadrant/per-patient frequency rules and additional notes (e.g., prior authorization or clinical condition requirements).

Periodontal scaling / root planing: D4240–D4241 limited to 1 per quadrant every 36 months and must be performed for appropriate disease-site indications.1 per quadrant per 36 months

Per-quadrant disease-site indications required

Osseous surgery: D4260–D4261 limited to 1 per quadrant every 36 months and indicated for specific osseous disease sites.1 per quadrant per 36 months

Clinical indications required

Gingival/soft tissue grafting: Codes in the D4266–D4286 series are subject to per-code limits (often 1 per tooth or lifetime or specified intervals) and some require prior authorization or are limited when performed for implant sites.

inv-08: Covered with frequency criteria

Coverage is indicated for listed D-codes when not violating the specified frequency limits or waiting periods.

Standard coverage condition: The procedure must correspond to a listed D-code and be performed after the specified waiting period (for example, not within 6 months of placement when noted) and no more frequently than the per-code interval (e.g., 12, 24, 60, 96 months) unless medical necessity is documented.per-code interval as listed

Some implant/abutment codes limited to 1 per lifetime or 96 months and limited to 4 overall unless medical justification is provided.

inv-09: Timing, maintenance, and replacement clinical criteria

Covered when the following timing and medical necessity rules are met

Implant crown/restoration intervals: Many implant crown and restoration codes (D6058–D6064 and similar) are limited to a repeat interval of 96 months per same implant site; some implant-related codes have other specified intervals or lifetime limits.intervals as listed (commonly 96 months)

Coverage may be limited to 4 units unless medical necessity justifies additional units

Repair and maintenance intervals: Implant maintenance and repair codes (e.g., D6081, D6090–D6091, D6095–D6096, D6190) are generally limited to 12 months; recementation/reline codes (D6092–D6093) are commonly limited to 2 years.12 months or 24 months as specified

Per-code intervals apply

Replacement prosthesis criteria (D6252 and related): Replacement of an implant-supported prosthesis (for example D6252) requires documentation of structural failure or new necessity, demonstration of broad loss of tooth/structure support, at least 50% resting bone support where required, and generally has a 60-month replacement interval.

inv-10: General coverage criteria for listed crown/prosthetic codes

Covered when ALL of the following are met

Primary coverage conditions: Listed crown and prosthetic procedures are covered when there is documented need for reconstruction (new prosthesis), at least 50% resting bone support where specified, and clinical justification demonstrating the change or failure necessitating replacement (excluding third molars unless medically necessary).>=50% bone support where indicated

Documentation must show new necessity and broad applied loss of structure

inv-11: Frequency limitations

Coverage limited by time since prior procedure on the same tooth

Timing constraints: Specific codes require waiting periods before replacement: examples include D6252, D6253, D6545 commonly every 60 months per same tooth; D6548 may be every 84 months; many crown/bridge and major prosthetic codes list 60-month intervals unless otherwise stated.60 months / 84 months

Applies per same tooth

inv-12: Prosthetic coverage criteria

Covered when ALL of the following are met

Prosthetic replacement requirements: Replacement or new prosthetic crowns/bridges requires documentation of new necessity, demonstration of broad loss of tooth structure due to disease/trauma or failure of prior restoration, and compliance with code-specific frequency intervals.

Must show clinical rationale and structural loss; third molars excluded unless medically necessary

Timing: Replacement is generally limited to once every 60 months per same tooth/quadrant for listed crown/bridge codes unless otherwise specified.60 months

Frequency restriction per code

Bone support: Where indicated by the code, at least 50% remaining bone support is required to establish eligibility for prosthetic replacement.>=50%

Clinical viability requirement

inv-13: Surgical and denture procedure frequency criteria

Coverage with frequency limits and per-tooth/per-quadrant rules

D6930 relines: D6930 (reline-related entries) limited to once every 24 months per quadrant.24 months per quadrant

Per-quadrant limit

D6980 repairs: D6980 (removable prosthesis repairs) limited to once every 60 months per patient unless otherwise noted.60 months

Per-patient interval

Surgical and extraction limits: Many extractions and oral surgery codes are limited to 1 per tooth or 1 per lifetime per patient as indicated by individual code descriptions.1 per lifetime / per tooth for many codes

See individual code entries for exact limits

inv-14: Covered when frequency and documentation rules are met

Coverage and frequency rules for listed CDT codes

Frequency limits apply: Codes specify limits such as '1 per lifetime', 'per 12 months', 'per 24 months', or 'per 60 months' and are covered only within those frequencies.per-code frequency as listed

Examples: biopsy/excision codes, vestibuloplasty frequencies, and many surgical codes include explicit intervals

Medical necessity and X‑ray documentation: Certain procedure codes explicitly require X‑ray and documentation of medical necessity for coverage (for example D7471–D7473 and select surgical codes).documentation required

Radiographs and clinical justification must be provided when stated

inv-15: General covered procedures with frequency limits

Covered when entries meet stated frequency limits and, where indicated, documentation of medical necessity is provided

General coverage conditions: Procedure is covered when it is a listed code performed no more frequently than its stated frequency (per lifetime, per 12/24/60/96 months) AND where entry states 'per report' or 'medical necessity', adequate supporting documentation is submitted.frequency limits as listed per code

See code group entries for exact limits (examples: D7951/D7953 one per lifetime per quadrant; many relines every 24 months)

inv-16: Service Limitations

Coverage is limited by described material and prosthesis considerations and by member eligibility and benefit limits.

Material/Prosthesis Limits: Coverage references limitations based on prosthesis type and materials (for example crowns: metal/ceramic/porcelain; implant-supported abutments and related components), and services may be influenced by available benefit alternatives and plan-specific eligibility.

Selection of prosthesis/material may affect coverage and payment; refer to benefit plan for limits

inv-17: Exclusions

Services and supplies explicitly excluded include:

Excluded Conditions/Services: Developmental or congenital anomaly corrections and related supplies; purely cosmetic procedures (esthetic enhancements, bleaching, cosmetic grafts); histopathology/laboratory tests and hospitalization charges for examinations; services not meeting accepted dental standards; procedures/supplies that are experimental or investigational; services covered under other programs (e.g., Medicare Advantage) as specified.

Consolidated exclusions from the policy text

inv-18: Complications — Billable Day Definition

Complication billing

Complication Treatment Day: A treatment complication day is defined as the day the treatment is complete and billable, examples include final cementation of crowns/bridges, final denture delivery, and removal of sutures; that day may be billed as the complication/complete treatment day per policy guidance.

Defines when a treatment day may be billed for complications

Some services are not covered when performed the same day as other specified services. Examples include evaluation codes such as D0120/D0140/D0150 which are not covered on the same day as certain observation/consultation or post‑procedure visit codes (see related code lines), and imaging/other procedure pairs that are restricted from same‑day billing by the policy. Follow the per‑code notes to determine forbidden same‑day combinations before submitting claims.

Third molars (wisdom teeth) are excluded from routine coverage except when medically necessary. Coverage for crowns, prostheses, and many restorative procedures specifically states exclusions for third molars unless documentation demonstrates a medical necessity for treatment of that tooth.

The policy reiterates that third molars are excluded unless medically necessary and also describes short non‑coverage windows after initial delivery of prostheses (commonly 6 months, or in some cases 12 months) during which relines, adjustments or similar services will not be covered. Verify the code‑specific waiting period before billing following delivery of a new appliance.

Certain procedures are not allowed when performed by the same provider or provider group on the same tooth or within specified intervals. The policy notes per‑tooth lifetime limits for select endodontic/restorative entries and disallows repeat submissions for the same tooth by the same provider group without meeting the stated clinical and frequency criteria.

Services performed within the specified non‑coverage window after placement of dentures or prostheses are not covered. Common examples: relines, soft‑liners, and many rebase/reline procedures are not covered within 6 months of placement and have per‑code frequency limits (e.g., many relines limited to 12 or 24 months depending on the code).

The policy specifies same‑day exclusions with hygiene/scaling services: procedures may be denied when billed on the same date as periodontal maintenance or prophylaxis (for example, certain implant scaling/maintenance codes are not covered on the same day as D4910 or D1110 when furnished in the same quadrant with codes such as D4241). Confirm same‑day rules for hygiene and quadrant‑based services prior to billing.

Third molars are explicitly referenced as exclusions in multiple eligibility sections for crown and prosthetic coverage. In those entries the requirement for structural support and applicable frequency intervals is stated to apply excluding third molars, unless a documented medical necessity justification is provided.

Prosthetic coverage entries reiterate that third molars are excluded from many crown/bridge replacement rules (phrased as coverage requirements that state ‘excluding third molars’). When third molars are the only teeth involved, coverage will generally not apply unless medical necessity is clearly documented.

The chunks in this area do not list additional explicit exclusions; rather they focus on per‑code frequency limits and clinical documentation requirements. For these entries, coverage is driven by meeting timing and medical necessity criteria rather than by enumerated exclusions in the excerpted text.

The policy lists categories of services and supplies that are excluded from coverage, including items that are experimental or investigational, services for cosmetic or aesthetic purposes (for example, cosmetic grafts or tooth bleaching), procedures to correct developmental or congenital anomalies when provided for cosmetic reasons, and charges for histopathology/laboratory tests or hospitalization when not separately covered. Services that do not meet accepted dental standards are also excluded.

The exclusions section gives specific examples of cosmetic and developmental exclusions: purely cosmetic procedures and esthetic enhancements (including bleaching and cosmetic grafts), corrections solely for developmental or congenital appearance, and other non‑medical aesthetic services. These items will be denied as not covered when the sole indication is cosmetic improvement.

Certain imaging and interpretation services are limited or require prior authorization; claims for advanced imaging (for example, CBCT/CT interpretation codes) will be denied if the clinical indication or prior‑authorization documentation is missing. Always check whether a prior authorization is required for codes such as D0364–D0368 and include supporting documentation when submitting requests.

Procedures that lack documentation demonstrating loss of tooth structure from disease or trauma, or that fail to show the minimum required remaining support, are not supported. The policy requires documentation of the degree of structural loss and, where specified, at least 50% remaining root/bone support for coverage of many crown and prosthetic services.

The policy states that procedures performed on third molars or those that do not meet stated clinical thresholds (for example, minimum bone or root support) are considered not medically necessary. Claims must demonstrate required clinical findings and thresholds to be eligible for coverage.

Denture adjustments and related services (for example, codes like D5410/D5411 and many reline/repair codes) are not covered if performed within the specified non‑coverage window after initial placement—commonly not covered within 6 months of placement—and are otherwise subject to the per‑code frequency limits (e.g., often 12 months for adjustments or relines).

Requests that exceed the stated frequency limits for a code or that lack medical justification for out‑of‑interval services are not covered. The policy consistently enforces per‑code frequency thresholds (for example, 12, 24, 60, 96 months or lifetime limits) and requires documentation if an exception for medical necessity is claimed.

Multiple implant and related prosthetic codes are described as limited to 4 units unless medical necessity is documented. Requests exceeding these numeric limits without appropriate clinical justification will be considered not medically necessary and may be denied.

Replacement or new prostheses that do not document a structural need for replacement or that fail to demonstrate minimum required support (commonly ≥50% resting bone support) will not meet coverage criteria. Claims for prosthetic replacement must include documentation showing new necessity and the minimum residual support when specified.

Replacements submitted without evidence of new clinical necessity, without documentation demonstrating broad loss of tooth structure, or without confirmation of required residual bone support may be denied. The policy requires clear clinical justification and supporting records for any prosthesis replacement requested before the specified interval has elapsed.

Services or supplies that do not meet accepted dental standards or that are deemed not medically necessary are excluded from coverage. The policy explicitly excludes experimental or investigational items, cosmetic‑only procedures, and other services listed in the exclusions section; these will be denied when submitted.

The document lists small restorations and certain restorative procedures as examples of items not supported where they are performed for cosmetic or non‑functional reasons. Small composite/amalgam restorations, appliances or procedures intended solely for occlusal maintenance or esthetic reasons are among those noted as not meeting coverage criteria when not clinically necessary.

CDT Codes and Frequency Key Values

Preventive and evaluation CDT codesmixedCovered

D0120	Periodic oral evaluation (one per 6 months)
D0140	Limited oral evaluation
D0150	Comprehensive oral evaluation (one per lifetime)
D0160	Detailed and extensive oral evaluation

Radiographic and diagnostic CDT codesmixedCovered

D0180	Comprehensive periodontal evaluation (every 6 months)
D0190	Screening of a patient
D0191	Assessment of a patient
D0210	Intraoral full series of radiographic images (per 36 months)
D0220	Periapical first radiographic image (three per 6 months per patient)
D0230	Periapical each additional radiograph (four per day of service)

Bitewing and extra/intraoral radiographymixedCovered

D0240	Intraoral occlusal radiograph (per 36 months)
D0250	Extraoral 2D projection radiographic image
D0251	Extraoral posterior dental radiographic image
D0270	Bitewing single radiograph (three per 12 months)
D0272	Bitewing two radiographs (three per 12 months)
D0273	Bitewing three radiographs (three per 12 months)
D0274	Bitewing four radiographs (three per 12 months)
D0277	Vertical bitewings (one per 12 months per tooth group)

Advanced imaging and TMJ codesmixedCovered

D0310	Sialography
D0320	Temporomandibular joint radiographic exam
D0321	Other TMJ radiographic film
D0330	Panoramic radiographic image (per 36 months)
D0340	Specialized oral/facial imaging (per 36 months)
D0350	2D intraoral imaging for implants (covered for implants)

Cone beam/CT imaging and interpretation (PA required)mixedCovered

D0364	Cone beam CT limited field (prior authorization required)
D0365	Cone beam CT complete (prior authorization required)
D0366	Interpretation of CBCT (prior authorization required)
D0367	CT scan (prior authorization indicated)
D0368	CT interpretation (prior authorization required)

Diagnostic, tele-dentistry, oral surgery diagnostic codesmixedCovered

D0391	Teledentistry asynchronous; allowed only when paired with D0701–D0709
D0460	Pulp vitality tests
D0470	Diagnostic casts (one per 12 months)
D0474	Diagnostic surgical pathology specimen
D0485	Oral pathology lab services
D0502	Other oral surgical/path procedures

Intraoral photographic/diagnostic imaging codesmixedCovered

D0701	Intraoral periapical radiograph - series (frequency per 36 months)
D0703	2-D intraoral periapical image (per 36 months)
D0706	Intraoral occlusal bilateral (2 per 12 months)
D0707	Intraoral occlusal per day (1 per day)
D0708	Intraoral occlusal between periapical images (2 per 12 months)
D0709	Intraoral series per 36 months (paired with D0701)

Preventive, prophylaxis, fluoride, restorative CDT codesmixedCovered

D0999	Unspecified diagnostic procedure
D1110	Prophylaxis (one per 6 months)
D1206	Topical fluoride varnish (up to 4 per 12 months)
D1208	Topical fluoride (specific forms)
D1320	Oral health counseling
D1354	Application of medicament (frequency limits apply)
D1355	Full mouth therapeutic application
D1999	Unspecified preventive/diagnostic procedure
D2140	Amalgam one surface primary
D2150	Amalgam two surfaces primary

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Restorative/filling and veneer codes referencedmixed

D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2391
D2392

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Crown and prosthesis codes (various crown types/materials)mixedCovered

D2710
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2753
D2780

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Crowns and related prosthetic codes (referenced together)mixed

D2710
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2753
D2780

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Resin-bonded inlay/onlay (D2910-D2915)CPT | mixedCovered

D2910
D2915

Cemented porcelain/ceramic inlay/onlay (D2920)CPT | mixedCovered

D2920

Prefabricated and prosthetic crown/restoration codesCPT | mixedCovered

D2928
D2931
D2932
D2933

Crown build-up, post and core, and prefabricated post codesCPT | mixedCovered

D2950
D2951
D2952
D2953
D2954
D2955
D2957
D2971

Endodontic and additional restorative procedure codesCPT | mixedCovered

D2980
D3110
D3120
D3220
D3230
D3240
D3310
D3320
D3330
D3331

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Restorative/related CDT codes (fragment)mixed

D3425	Code listed in document fragment
D3426	Code listed in document fragment
D3430	Code listed in document fragment
D3351	Code listed in document fragment
D3352	Code listed in document fragment
D3353	Code listed in document fragment
D3450	Code listed in document fragment
D3470	Code listed in document fragment

Periodontal codes (part)mixed

D3920	Hemisection (fragment)
D3921	Unspecified extraction/emergency-related (fragment)
D3999	Unspecified endodontic/other per medical necessity
D4210	Gingivectomy / gingival surgery (fragment)
D4211	Gingivectomy / gingival surgery (fragment)
D4212	Gingivectomy (localized) (fragment)

Periodontics / soft tissue / maintenance codesmixed

D4240	Periodontal scaling and root planing (per quadrant)
D4241	Periodontal scaling and root planing (per quadrant)
D4245	Procedure noted with prior authorization language
D4249	Other periodontal procedure
D4260	Osseous surgery (per quadrant)
D4261	Osseous surgery (per quadrant)
D4266	Guided tissue regeneration - resorbable
D4267	Guided tissue regeneration - non-resorbable
D4270	Pedicle soft tissue graft
D4273	Subepithelial connective tissue graft

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Prosthodontics / denture codes and maintenancemixed

D5110	Complete denture - maxillary
D5120	Complete denture - mandibular
D5130	Immediate denture
D5140	Immediate denture - mandibular
D5211	Complete denture - maxillary (alternative grouping)
D5212	Complete denture - mandibular (alternative grouping)
D5213	Complete denture - maxillary (retentive variation)
D5214	Complete denture - mandibular (retentive variation)
D5225	Overdenture - maxillary
D5226	Overdenture - mandibular

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Reline complete denture codesCPTCovered

D5410	Reline complete denture — chairside (per 12 months; not covered within 6 months of placement)
D5411	Reline complete denture — laboratory (per 12 months; not covered within 6 months of placement)

Reline and repair partial/complete denture codesCPTCovered

D5421	Reline partial denture — chairside (per 12 months; not covered within 6 months of placement)
D5422	Reline partial denture — laboratory (per 12 months; not covered within 6 months of placement)
D5511	Repair broken complete denture base (per 12 months)
D5512	Repair broken partial denture base (per 12 months)
D5520	Replace missing or broken clasp — per clasp (per 12 months)

Repair/addition/insert denture codesCPTCovered

D5611	Repair removable partial denture — resin tooth (per 12 months)
D5612	Repair removable partial denture — cast framework (per 12 months)
D5621	Repair maxillary partial denture framework (per 12 months)
D5622	Repair mandibular partial denture framework (per 12 months)
D5630	Repair broken clasp or retentive/attachment per clasp (per 12 months)
D5640	Replace broken teeth on denture (per 12 months)
D5650	Add tooth to existing partial denture (per 12 months)
D5660	Add clasp to existing partial denture (per 12 months)
D5670	Insert interim complete denture
D5671	Insert immediate partial denture (per 12 months)

Rebase denture codesCPTCovered

D5710	Rebase complete denture (per 60 months; not covered within 6 months of placement)
D5711	Rebase complete denture (alternative description) (per 60 months; not covered within 6 months of placement)
D5720	Rebase maxillary denture (per 60 months; not covered within 6 months of placement)
D5721	Rebase mandibular denture (per 60 months; not covered within 6 months of placement)

Reline/soft-liner frequency codesCPTCovered

D5730	Reline complete upper denture (per 12 months)
D5731	Reline complete lower denture (per 12 months; not covered within 6 months of placement)
D5740	Reline maxillary partial denture (per 12 months; not covered within 6 months of placement)
D5741	Reline mandibular partial denture (per 12 months; not covered within 6 months of placement)
D5750	Chairside hard reline complete denture (per 24 months; not covered within 6 months of placement)
D5751	Lab processed hard reline complete denture (per 24 months; not covered within 6 months of placement)
D5760	Chairside hard reline partial denture (per 24 months; not covered within 6 months of placement)
D5761	Lab processed hard reline partial denture (per 24 months; not covered within 6 months of placement)
D5765	Soft liner — indirect (per 24 months; not covered within 6 months of placement)

Tissue conditioning and specialty prosthesis codesCPTCovered

D5850	Tissue conditioning, maxillary (per 60 months)
D5851	Tissue conditioning, mandibular (per 60 months)
D5899	Unspecified removable prosthodontic procedure (medical necessity required)
D5911	Obturator — nasal (per 12 months)
D5912	Obturator — other (per 12 months)
D5913	Speech-related prosthesis (per 12 months)
D5914	Urological/related prosthesis (per 12 months)
D5915	Thesis/other prosthetic device (per 12 months)
D5916	Ocular prosthesis (per 12 months)

Specialty prosthesis and related codesCPTCovered

D5919	Special prosthesis (per 2 months for up to 6 units)
D5922	Nasal septal prosthesis (per 12 months)
D5923	Ocular prosthesis interim (per 12 months)
D5924	Cranial prosthesis (per 12 months)
D5925	Palatal augmentation prosthesis (per 12 months)
D5926	Nasal prosthesis (per 12 months)
D5927	Auricular prosthesis (per 12 months)
D5928	Arbitrary prosthesis — partial (per 12 months)
D5929	Facial prosthesis (per 12 months)
D5931	Obturator surgical (per 12 months)

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Surgical/oncologic prosthesis and adjunct codesCPTCovered

D5982	Surgical stent (per 12 months)
D5983	Radiation carrier (per 12 months)
D5984	Radiation shield (per 12 months)
D5985	Radiation spacer/locator (per 12 months)
D5986	Ridge augmentation material (two units per 12 months)
D5987	Custom surgical guide (per 12 months)
D5988	Surgical mirror (per 12 months)
D5999	Unspecified maxillofacial prosthesis (medical necessity required)

Implant placement, abutment, and implant crown codesCPTCovered

D6010	Surgical placement of implant (endosteal) — lifetime/1 per site; limited to 4 unless medical reason
D6013	Mini surgical implant placement — same limits as D6010
D6055	Titanium abutment-supported crown/overdenture component (limited)
D6056	Prefabricated abutment (per 96 months)
D6057	Custom abutment (per 96 months)
D6058	Implant-supported crown/partial (per 96 months)
D6059	Implant-supported crown fused to metal (per 96 months)
D6060	Implant-supported crown — high noble metal (per 96 months)
D6061	Implant-supported crown — noble metal (per 96 months)
D6062	Implant-supported crown — base metal (per 96 months)

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Implant-supported crown codes with 96-month intervalCPTCovered

D6058	implant-supported restoration (96-month interval)
D6059	implant-supported restoration (96-month interval)
D6060	implant-supported restoration (96-month interval)
D6061	implant-supported restoration (96-month interval)
D6062	implant-supported restoration (96-month interval)
D6063	implant-related code (96-month interval)
D6064	implant-related code (96-month interval)

Alternate implant crown codes (96-month interval)CPTCovered

D6065	implant-supported partial crown/related
D6066	implant-supported crown - high noble metal
D6067	implant-supported crown - high noble

Implant maintenance (12 months)CPTCovered

D6081

implant scaling and debridement (per 12 months)

Implant repair, recementation, and component maintenanceCPTCovered

D6090	repair of implant prosthesis (per 12 months)
D6091	repair of abutment/attachment (per 12 months)
D6092	re-cement/re-bond implant-supported crown (per 2 years)
D6093	relining/repair of implant denture (per 2 years)
D6094	implant-supported crown - titanium (per 8 years; limits apply)
D6095	implant prosthesis repair (per 12 months)
D6096	replacement of retaining screw (per 12 months)

Surgical implant site procedures and graftingCPTCovered

D6100	surgical procedures related to implant - medical necessity required
D6101	debridement of peri-implant defect (per 2 years)
D6102	debridement plus access and regenerative procedures (per 2 years)
D6103	bone graft for peri-implant defect (per 2 years)
D6104	bone graft at time of implant placement (lifetime per implant)

Guided tissue regeneration codesCPTCovered

D6106	guided tissue regeneration with resorbable membranes (lifetime per implant)
D6107	guided tissue regeneration non-resorbable (lifetime per implant)

Implant-supported denture/removal/repair codesCPTCovered

D6110	implant-supported overdenture - removable (per 96 months)
D6111	implant-supported overdenture - removable, alternative code (per 96 months)
D6112	implant-supported overdenture - partial (per 96 months)
D6113	implant-supported overdenture - alternate (per 96 months)

Diagnostic, attachment, and miscellaneous implant codesCPTCovered

D6190	radiographic implant index/diagnostic (per 12 months)
D6191	precision attachment overdenture (per 96 months)
D6192	implant pick-up impression/accurate indexing (per 96 months)
D6193	replacement of implant screw
D6199	unspecified implant procedure (medical necessity required)

Major implant prosthesis and replacement codesCPTCovered

D6210	implant-supported prosthesis codes (group)
D6211	implant prosthesis variant
D6212	implant prosthesis variant
D6214	implant prosthesis variant
D6240	prosthesis - fixed implant-supported
D6241	prosthesis - fixed implant - alternative
D6242	fixed prosthesis components
D6243	fixed prosthesis components
D6245	fixed prosthesis components
D6250	implant prosthesis component

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Referenced CDT/D procedure codesmixed

D6210
D6211
D6212
D6214
D6240
D6241
D6242
D6243
D6245
D6250

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Crown/abutment/prosthetic codes mentioned togetherCPTCovered

D6720
D6721
D6722
D6740
D6750
D6751
D6752
D6753
D6780
D6781

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Additional oral surgery/prosthodontic codes with frequenciesCPTCovered

D6930	Reline - chairside or lab (per quadrant) (24-month limit)
D6980	Repair, removable prosthesis — 60 month limit
D6999	Unspecified prosthodontic procedure
D7111	Extraction, coronal remnants—primary tooth
D7140	Extraction, non-surgical; erupted tooth or exposed root
D7210	Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth
D7220	Removal of impacted tooth — soft tissue
D7230	Removal of impacted tooth — partially bony
D7240	Removal of impacted tooth — completely bony
D7241	Removal of impacted tooth — completely bony with unusual surgical complications

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Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization required for selected advanced imaging

Prior authorization (pre-service review) is required for specific advanced imaging and interpretation services including cone beam CT and CT codes D0364–D0368; obtain PA before scheduling these studies.

Examples: D0364, D0365, D0366, D0367, D0368 require prior authorization.
PA is required to verify clinical indication and benefits before service.

Prior Authorization

Follow code-specific frequency and documentation requirements

Many restorative and crown D-codes carry specific frequency and structural documentation requirements; providers must document clinical need and respect per‑tooth timing (e.g., common replacement intervals of 24 or 60 months) and submit PA where indicated by the code notes.

Examples: single‑tooth restorations limited to 24 months; crowns/prostheses commonly limited to 60 months per same tooth.
Documentation must show loss of tooth structure due to disease/trauma and meet minimum support thresholds where stated.

Background and Scope

Procedures lacking documentation of disease‑ or trauma‑related loss of structure, or those showing insufficient remaining support (less than 50% remaining root/bone support), are considered not medically necessary under the policy. Documentation must demonstrate both the etiologic cause and the degree of structural compromise to support coverage.

Key Definitions and Policy Terms

Frequency limits — Per-member limits attached to procedure codes (per day/per 6 months/per 12 months/per 36 months/per lifetime)

Frequency typesPer day / per 6 months / per 12 months / per 36 months / per lifetime (code‑specific)

ExamplesD0120/D1110: per 6 months; D0210/D0330: per 36 months; many crowns: per 60 months; some implants: per 96 months

ActionRefer to the specific CDT line for the exact per‑member limit and waiting periods

Prior authorization — Advance approval required for certain imaging and specialized services

RequirementPrior authorization required for select advanced imaging/interpretation codes (e.g., D0364–D0368)

ExamplesCBCT/CT and interpretation codes listed with 'prior authorization required' language

Policy Summary

PayerFidelis Care

PolicyDental benefits coverage criteria (CDT codes, frequency, prior authorization)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit required clinical documentation (including X-rays) for listed imaging, implant, and prosthetic procedures when indicated.

SourceLink

On This Page

per code-specific limits

See individual code lines for implant-only coverage and prior authorization

Periodontal maintenance and adjuncts: Periodontal maintenance and full-mouth debridement codes (D4341/D4342/D4346/D4355/D4381/D4910) have specified intervals (commonly 24 months for many entries, D4910 noted per 6 months usage) and have same-day/service restrictions with certain hygiene codes.varies by code (24 months, 6 months, or as specified)

Do not bill conflicting same-day codes in the same quadrant

Prosthodontics — dentures/replacements: D5110–D5226 and related denture codes: replacement or new complete/partial dentures are generally limited to once every 96 months; repairs/adjustments and immediate denture entries have shorter intervals and some services are not covered within 6 months of placement.most replacement prostheses: 96 months; many adjustments/repairs: 12 months

See denture subgroup for per-code waiting periods

60 months; >=50% bone support when required

May require documentation and/or prior authorization

Tooth availability/third molar exclusion: Policy excludes third molars from certain prosthetic eligibility statements; coverage applies when the affected tooth meets the stated clinical and timing conditions.

Third molar exclusions stated in code entries

Selected biopsy/excision CDT codesmixedCovered

D7280	Listed with frequency/description
D7282	Listed with frequency/description
D7283	Listed with frequency/description
D7285	Incisional biopsy of oral hard tissue (1 per 12 months)
D7286	Incisional biopsy of oral soft tissue (1 per 12 months)
D7287	Excisional or exploratory specimen (per 24 months)
D7288	Excisional biopsy (per 24 months)

Alveoloplasty/vestibuloplasty codesmixedCovered

D7310	Alveoloplasty in conjunction with extractions (1–4 tooth spaces)
D7311	Alveoloplasty not in conjunction with extractions (1–4 tooth spaces)
D7320	Alveoloplasty not in conjunction with extractions (1–3 tooth spaces)
D7321	Alveoloplasty not in conjunction with extractions (4+ tooth spaces)
D7340	Vestibuloplasty
D7350	Vestibuloplasty — alternate

Excision/biopsy lesion codesmixedCovered

D7410	Excision of benign lesions up to 1.25 cm
D7411	Excision of benign lesions greater than 1.25 cm
D7412	Excision of malignant lesions up to 1.25 cm
D7413	Excision of malignant lesions greater than 1.25 cm
D7414	Excision of malignant lesions with complications
D7415	Excision of malignant lesions (additional descriptor)
D7440	Excision of malignant lesion >1.25 cm
D7441	Excision with other specified descriptors
D7450	Biopsy/diagnostic procedure for specified lesions
D7451	Biopsy/diagnostic procedure — descriptor

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Excision/resection and inpatient codes with documentation notesmixedCovered

D7471	Excision of oral lesion — per quadrant; X‑ray required/medical necessity
D7472	Excision of oral lesion — per quadrant; X‑ray required/medical necessity
D7473	Excision of oral lesion — per quadrant; X‑ray required/medical necessity
D7485	Surgical reduction of tuberosity — 1 per lifetime per patient
D7490	Resection of lesion or related mandibular/maxillary resection
D7509	Inpatient/operative day surgical procedure (1 per day of service)

Abscess/drainage and foreign body codesmixedCovered

D7510	Incision and drainage of abscess - intraoral soft tissue
D7511	Incision and drainage of abscess - intraoral with extensions
D7520	Incision and drainage of abscess - extraoral soft tissue
D7521	Incision and drainage - extraoral with multiple spaces
D7530	Removal of foreign body from soft tissue
D7540	Diagnostic/surgical exploration

Oral/maxillofacial surgical and anesthesia codes (wide group)mixedCovered

D7550	Partially impacted tooth removal
D7560	Maxillary sinusotomy for removal of foreign body
D7610	Open reduction — specified mandibular/maxillary procedures
D7620	Open reduction with fixation
D7630	Mandibular open reduction
D7640	Mandibular closed reduction
D7650	Maxillofacial open reduction
D7660	Maxillofacial closed reduction
D7670	Stabilization splinting or closed reduction splinting
D7671	Open reduction with stabilization

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Oral/Temporomandibular arthroscopy codesCPTCovered

D7865	Arthroplasty with prosthetic or graft
D7870	Aspiration — referenced with 6-month frequency
D7872	Arthroscopy biopsy
D7873	Arthroscopy surgical
D7874	Arthroscopy - disk repair/stabilization
D7875	Arthroscopy - surgical synovectomy
D7876	Arthroscopy - discectomy

Surgical/orthognathic procedure codesCPTCovered

D7880	Occlusal guard; listed with 12-month frequency
D7899	Unspecified TMD therapy (per report)
D7910	Suture — small wound
D7911	Complex suture
D7912	Complex suture (>5 cm)
D7920	Skin graft identification
D7940	Osteotomy - orthognathic deformity
D7941	Osteotomy - mandibular ramus
D7943	Osteotomy with bone graft
D7944	Segmental osteotomy

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Implant / soft tissue / grafting codesCPTCovered

D7951	Sinus augmentation — one per lifetime per quadrant; covered only for implant site
D7952	Sinus augmentation with vertical component — prior authorization required
D7953	Bone graft for ridge augmentation — one per lifetime per quadrant; covered only for implant site
D7961	Buccal/ labial frenectomy
D7962	Lingual frenectomy
D7970	Excision of hyperplastic tissue
D7971	Excision of pericoronal gingiva (24-month limit)
D7972	Surgical reduction of fibrous tuberosity

Other oral surgery and emergency codesCPTCovered

D7980	Sialolithotomy (surgical salivary stone removal)
D7981	Excision of salivary gland lesion
D7982	Sialoadenectomy
D7983	Closure of salivary fistula
D7990	Emergency treatment of traumatic injuries
D7991	Extraction of erupted tooth
D7997	Bite adjustment
D7998	Oral/Maxillofacial fixation — internal fixation devices
D7999	Unspecified oral surgery

Anesthesia and sedation codesCPTCovered

D9110	Palliative (emergency) treatment of dental pain
D9120	Prosthesis repair (denture section)
D9219	General anesthesia evaluation
D9222	Deep sedation/analgesia (first 15 minutes)
D9223	Deep sedation/analgesia — additional 15-minute increments
D9230	Nitrous oxide

Consultation/observation and related codesCPTCovered

D9239	Intravenous moderate (conscious) sedation/analgesia
D9243	Intravenous sedation each 15 minutes
D9310	Consultation — detailed
D9430	Office visit for observation
D9440	Office visit — related

Prosthodontic maintenance and medicament codesCPTCovered

D9610	Therapeutic medication injection
D9612	Therapeutic medication injection, additional
D9911	Desensitizing medicament application — once per 24 months per tooth
D9930	Application of medicament to complicated surgical area
D9932	Reline and evaluation removable partial denture (maxillary) — every 24 months
D9933	Reline removable partial denture (mandibular) — every 24 months
D9934	Reline maxillary complete denture — every 24 months
D9935	Reline mandibular complete denture — every 24 months
D9942	Occlusal adjustment — once every 24 months
D9944	Occlusal guard - severe

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Teledentistry and unspecified adjunctive codesCPTCovered

D9990	Interpretation of tests/translation services — tele-dentistry noted
D9991	Teledentistry asynchronous
D9995	Teledentistry - synchronous
D9996	Teledentistry - asynchronous
D9997	Teledentistry - special needs
D9999	Unspecified adjunctive procedure

Document does not list explicit codes in this sectionmixed

No codes listed

Prophylaxis frequency — D1110: one per 6 months

CodeD1110

LimitOne prophylaxis per member every 6 months

NotesNot covered same day as certain services when specified in code lines

Comprehensive evaluation frequency — D0150: one per lifetime

CodeD0150

LimitOne comprehensive oral evaluation per lifetime

NotesNot covered same day as certain other services as listed in code lines

Replacement frequency (some restorations) — 24 months

Replacement interval24 months (many single‑tooth restorations)

Applies toSelect restorative codes and small restorations as listed (per same tooth)

ConditionReplacement requires documentation of need and minimum structural support where specified

Replacement frequency (crowns/prostheses) — 60 months

Replacement interval60 months (crowns and many prostheses per same tooth)

Applies toVarious crown/bridge/prosthetic D‑codes listed in the policy (replacement/new prosthesis)

RequirementDocumentation of new necessity and structural criteria required for coverage

Minimum structural support — >= 50% remaining root/bone support

ThresholdMinimum 50% remaining root/bone support

Applies toCertain crown/prosthesis coverage and replacements requiring structural support

ExclusionThird molars excluded unless medically necessary

Minimum resting bone support — >= 50%

Threshold>= 50% resting bone support

Applies toEligibility for specified prosthetic services and replacements (per code lines)

DocumentationRadiographic/clinical evidence required to demonstrate bone support

Frequency limit for D2910-D2915 — 1 per tooth per 12 months; not covered within 6 months of delivery

CodesD2910–D2915

LimitOne per tooth per 12 months

Waiting‑periodNot covered within 6 months of delivery/placement

Frequency limit for D2920 — 1 per tooth per 24 months; not covered within 12 months of delivery

CodeD2920

LimitOne per tooth per 24 months

Waiting‑periodNot covered within 12 months of delivery/placement

Frequency limit for D2928/D2931-D2933 — 1 per tooth every 60 months

CodesD2928; D2931–D2933

LimitOne per tooth every 60 months

NotesThird molars excluded unless medically necessary; code‑specific conditions apply

Frequency limits examples — per tooth/per lifetime; per quadrant every 36 months; periodontal maintenance etc.

Examples of limitsPer tooth (e.g., 1 per tooth per X months) and per lifetime limits

Per quadrant exampleD4240–D4241, D4260–D4261: 1 per quadrant every 36 months

Maintenance/otherPeriodontal maintenance and many denture adjustments: per 12–24 months as listed

Frequency/Time thresholds — examples including 2 months, 6 months, 12 months, 24 months, 96 months

Common intervalsExamples include 2 months, 6 months, 12 months, 24 months, 60 months, 96 months

Context2 months (certain D5919 units), 6 months (non‑coverage windows after placement), 12 months (many denture services), 24 months (relines/repairs), 96 months (major prosthesis/implant replacements)

ApplicationIntervals are code‑specific; check the code line for exact timing and waiting periods

Bone support threshold — >= 50% resting bone support required for certain prosthesis replacements

Threshold>= 50% resting bone support required

Applies toCertain prosthesis replacements (implant‑supported replacements, crown/bridge replacements)

DocumentationRadiographic evidence and clinical justification required to demonstrate remaining bone support

Frequency limits per same tooth — varies by code (commonly 60 months; D6548 = 84 months)

SummaryFrequency limits per same tooth vary by code; common repeat interval is 60 months

ExceptionsSome codes have different intervals (example: D6548 = 84 months)

ActionVerify the specific code line for the exact per‑tooth interval before submitting

Minimum residual bone support — >= 50% resting bone support

Threshold>= 50% resting bone support (minimum residual bone support)

Applies toEligibility for many crown/implant/prosthetic replacements

RequirementMust be documented (X‑ray/clinical) to support replacement claims

Remaining bone support — >= 50%

Threshold>= 50% remaining bone support

UsageRequired where indicated for crown/bridge and implant prosthesis coverage

ExclusionThird molars excluded unless medically necessary

Crown/bridge replacement interval — 60 months

Interval60 months

Applies toCrown and bridge replacements (per same tooth) as listed in the crown/prosthetic code groups

DocumentationReplacement requires evidence of new necessity and structural criteria

D6930 frequency — 24 months per quadrant

CodeD6930

LimitOne reline per quadrant every 24 months

NotesPer‑quadrant timing; verify quadrant at time of service

D6980 frequency — 60 months per patient

CodeD6980

LimitOne per patient every 60 months

NotesApplies to repair/removable prosthesis entries as listed

Lesion size thresholds — 1.25 centimeters (used to differentiate code selection for excision)

Threshold1.25 centimeters

UseSize threshold to differentiate excision/biopsy code selection (lesion ≤ or > 1.25 cm)

ActionDocument lesion size in medical record to support code choice

Per-member frequency limits examples — one per lifetime per quadrant; two per 12 months per patient; many relines every 24 months

ExamplesOne per lifetime per quadrant (D7951/D7953); two per 12 months per patient (D9110 examples); many relines every 24 months

InterpretationPer‑member limits vary by code and may be per tooth, per quadrant, per patient, or per lifetime

Provider actionConfirm per‑member limits on the specific code line before claim submission

Prior Authorization

Lifetime limits and minimum bone support required

Certain endodontic and prosthetic items are lifetime‑limited and require demonstration of adequate support; for example, D3110 and D3120 are limited to one per tooth per lifetime and require at least 50% resting bone support.

D3110 and D3120: 1 per tooth per lifetime; documentation must show ≥50% resting bone support.
Replacement requests without required support or clinical rationale risk denial.

Prior Authorization

Prior authorization required for select periodontal/soft‑tissue procedures

Some periodontal and soft‑tissue procedures are marked 'Prior authorization required' in the policy (examples include select grafting/soft‑tissue codes such as D4245 and D4277); obtain PA when indicated by the code entry.

Codes flagged with 'Prior authorization required' must be pre‑authorized before service.
Check the individual code line for PA instructions.

Billing Rule

Observe implant and abutment frequency and quantity limits

Implant placement, abutment and implant crown services have lifetime or long interval limits (some limited to 1 per life or to 96 months) and may be limited to a maximum number per member unless medical necessity is documented.

Examples: D6010/D6013 limited to 1 per life per site and limited to 4 overall unless medical reason; many implant crown/abutment codes (D6056–D6064) have 96‑month intervals.
When exceeding numeric limits, document medical necessity to support coverage.

Prior Authorization

D6252: 60‑month replacement interval and required documentation

When replacing an implant‑supported prosthesis (e.g., D6252), providers must document the replacement criteria and respect the 60‑month interval; replacement requires evidence of structural failure/new necessity and applicable bone support.

D6252: replacement requires meeting replacement criteria and has a 60‑month interval per same site.
Documentation must show broad loss of tooth structure or structural failure and ≥50% resting bone support where required.

Billing Rule

Respect explicit code frequency constraints or provide justification

Several specific codes carry explicit frequency constraints (examples: D6252, D6253, D6545, D6548); submit claims only after the listed interval or include supporting documentation of new medical necessity if submitted earlier.

Examples: D6252 and D6253 — 60 months per same tooth; D6545 — 60 months; D6548 — 84 months.
If requested sooner, include clinical justification and supporting documentation.

Prior Authorization

Codes with frequency limits require review or PA

Certain surgical and prosthetic procedures require review when frequency limits apply (examples: D6930 limited to 24 months per quadrant; D6980 limited to 60 months per patient); prior authorization or claim review may be needed when these codes are billed.

D6930: relines limited to once every 24 months per quadrant.
D6980: removable denture repairs cited with a 60‑month interval per patient.

Documentation Required

Maintain documentation to support frequency‑limited services

Many CDT entries include per‑member frequency limits (e.g., 1 per lifetime, per 12 months, per 24 months); providers must maintain documentation to support timing and be prepared for claim review when frequencies are near policy limits.

Examples: biopsy/excision codes (D7285/D7286: 12 months; D7287/D7288: 24 months).
Maintain supporting clinical records and dates of prior services to demonstrate compliance.

Prior Authorization

Prior authorization required for select sinus augmentation/grafting

Sinus augmentation procedures with vertical component (D7952) and other select implant‑related grafting procedures require prior authorization; obtain PA before scheduling these services.

D7952 is explicitly listed as 'Prior authorization required'.
D7951/D7953 also have lifetime or quadrant limits and are covered only for implant sites.

Prior Authorization

Obtain pre‑service authorization when indicated

Pre‑service authorization (PA) is required to verify coverage, eligibility, and available benefits prior to dental treatment when the policy indicates PA; providers must request PA to confirm benefit availability.

PA verifies member eligibility and benefit limits at time of request.
Obtain PA when a code entry or policy note indicates 'prior authorization required'.

Billing Rule

Tele‑dentistry must be billed with required diagnostic intraoral images

D0391 tele‑dentistry (asynchronous) is allowed only when billed together with diagnostic intraoral imaging codes D0701–D0709 as specified; pair the tele‑dentistry code with the required imaging when submitting claims.

D0391 allowed only when accompanied by D0701–D0709.
Failure to bill the required imaging pairing may lead to denial.

Step Therapy

No explicit step‑therapy sequences specified

The policy does not define step‑therapy sequencing for dental procedures; coverage is governed by structural criteria, frequency limits, and documentation requirements rather than staged clinical steps.

No explicit step therapy sequences are listed in the document.
Coverage decisions rely on meeting code‑specific frequency and clinical documentation rules.

Documentation Required

Document imaging and tele‑dentistry with clinical justification

Providers must supply imaging and clinical documentation for tele‑dentistry and advanced imaging requests — diagnostics must support the clinical reason and interpretation; tele‑dentistry (D0391) requires associated intraoral images.

Imaging/interpretation services require clinical indication and supporting documentation per code notes.
D0391 must be paired with D0701–D0709 and documentation of the clinical concern.

Documentation Required

Provide clinical documentation of structural loss and ≥50% support

Clinical documentation is required to demonstrate loss of tooth structure due to disease or trauma and to document remaining root/bone support (≥50%) for crowns and prostheses; include broad tooth‑structure evidence when requesting replacements.

Policy requires documentation of loss of tooth structure and at least 50% remaining root/bone support for many prosthetic/crown services.
Third molars are excluded unless medically necessary — document medical necessity if applicable.

Billing Rule

Ensure claims respect code frequency and waiting‑period rules

Claims must reflect applicable frequency and timing limits (e.g., D2910–D2915: 1 per tooth per 12 months and not within 6 months of delivery); do not submit claims within restricted non‑coverage windows unless clinical justification is documented.

D2910–D2915: 1 per tooth every 12 months; not covered within 6 months of delivery.
D2920: 1 per tooth every 24 months; not covered within 12 months of delivery.

Documentation Required

Include required X‑rays and radiographic interpretation with claims

X‑ray and other diagnostic images are required per code notes when 'X‑Ray required - medical necessity' or 'per report' language appears; absence of required radiographs or interpretation may lead to denial.

Examples: D7471–D7473 include explicit 'X‑Ray required - medical necessity' language.
Include radiographs and a clear statement of medical necessity with the claim.

Documentation Required

Provide medical necessity documentation for implant services exceeding limits

When implant limits (quantity or interval) are exceeded, providers must document medical necessity and surgical rationale; lack of medical necessity documentation for implant placement/related surgical procedures risks denial.

Implant placement codes limited to 1 per life per site and to a maximum number (often limited to 4 unless medical reason).
Surgical implant site procedures and grafting require documentation of medical necessity when limits are exceeded.

Documentation Required

Document clinical necessity for prosthetic replacements

Clinical documentation supporting a new prosthesis must show reconstruction need, broad loss of tooth structure, and minimum resting bone support (≥50%); replacements failing to show new necessity and structural support are at risk for denial.

Replacement requests (crowns/bridges/prostheses) require evidence of new necessity and ≥50% resting bone support where indicated.
Requests exceeding the 60‑month replacement interval require documentation that a new prosthesis is clinically necessary.

Documentation Required

Verify eligibility and retain dental records for payment

Coverage determination and payment require member eligibility on the date of service and adequate dental record documentation; providers must verify eligibility and retain records to support claims.

PA verifies coverage and available benefits at time of request; payment depends on member eligibility on date of service.
Maintain dental records and documentation to support clinical and frequency requirements.

Prior Authorization

PA triggers: CBCT/CT imaging and interpretation codes

Prior authorization is a trigger for several listed imaging and advanced services (notably D0364–D0368); providers should request PA for these codes to avoid pre‑service denials.

Examples: D0364, D0365, D0366, D0367, D0368 are annotated as requiring prior authorization.
Failure to obtain PA for these codes can result in denied services.

Denial Risk

Denial risk: missing clinical or radiographic support

Insufficient clinical documentation—such as failure to document adequate tooth structure, lack of required radiographs, or missing evidence of ≥50% remaining bone support—may result in claim denial.

Absence of required documentation for minimum structural support (≥50%) risks denial.
Lack of required X‑rays or 'per report' documentation will trigger denial where specified.

Denial Risk

Denial risk: excluded teeth or unmet clinical thresholds

Services that do not meet stated clinical thresholds (for example, procedures on third molars without medical necessity or procedures lacking required resting bone support) may be excluded or denied.

Third molars are excluded unless medically necessary — document the indication when applicable.
Procedures lacking ≥50% resting bone support are at risk for non‑coverage.

Denial Risk

Denial risk: frequency and waiting‑period violations

When services are billed within non‑covered waiting periods (e.g., replacements or relines billed within 6 months of initial placement) or more frequently than policy intervals, claims may be denied for frequency/waiting‑period violations.

Examples: relines/repairs not covered within 6 months of placement; many denture services have 12‑ or 24‑month intervals and replacements 96 months.
Check prior delivery dates before submitting replacement or adjustment claims.

Denial Risk

Same‑day exclusion risk — avoid disallowed code combinations

Same‑day exclusions apply for specified combinations (for example, implant scaling/debridement or certain surgical services billed the same day as D0120/D1110 in the same quadrant); avoid billing disallowed same‑day code combinations.

D6081 (implant scaling/debridement) is not covered the same day as D4910 or D1110 in the same quadrant when specified.
Check the code notes for same‑day exclusions before billing multiple codes on one day.

Denial Risk

Denial trigger: experimental or non‑standard services

If a requested service is experimental, investigational, or otherwise not meeting accepted dental standards, it is a denial trigger; providers must document accepted standard of care and necessity.

Experimental or investigational supplies/procedures are excluded.
Provide standard‑of‑care justification and documentation when treatment may appear novel.

Provider actionObtain pre‑service authorization where specified to avoid denials

Minimum structural support — Requirement that at least 50% of the root/bone support remains for certain crown/prosthesis coverage

Threshold>= 50% remaining root/bone support

Applies toCertain crown/prosthesis coverage and implant prosthesis replacements

DocumentationClinical and radiographic evidence required to demonstrate support

Frequency limit (same tooth/patient) — Many codes specify replacement no more frequently than every 24 or 60 months

Typical intervalsMany replacement codes: no more frequently than every 24 or 60 months per same tooth/patient

ExamplesD6252, D6253, D6545 typically every 60 months; some codes longer (D6548 = 84 months)

ActionVerify code‑specific interval before approving/replacing prosthesis

Minimum resting bone support — Clinical requirement stated as at least 50% resting bone support for certain prosthetic services

Threshold>= 50% resting bone support

ContextClinical requirement for certain prosthetic and implant replacements (documented by X‑ray/records)

ConsequenceLack of required support may result in denial or noncoverage

Medical necessity / X-Ray — References to X-Ray and 'per medical necessity' for unspecified procedures

NoteX‑rays may be required 'per medical necessity' for certain procedures (e.g., unspecified D3999 entries)

ActionInclude radiographic images and clinical justification when policy notes 'X‑Ray required - medical necessity'

ExamplesVarious surgical and implant codes reference imaging and documentation requirements

Waiting-period/not-covered timeframe — Examples of 'not covered within 6 months of placement' language

Waiting periodsNon‑coverage windows commonly include 'not covered within 6 months of placement' for relines/rebases/relines','not covered within 12 months' for some restorations

ExamplesD5410/D5411 not covered within 6 months of placement; D2920 not covered within 12 months; many relines/repairs have 6‑month exclusions

Provider actionDo not submit claims within the specified waiting period unless medical necessity is documented

Debridement/maintenance (implant) — Procedures such as scaling/debridement of implant surfaces with specified intervals

ExamplesD6081 and D6090–D6096: implant maintenance/repair codes with specified intervals; D6081: 12 months; recementation/repairs often 24 months or 12 months

ActionFollow per‑code maintenance intervals for implant debridement, recementation, and repairs

NotesSome implant crown/components limited to 96 months or longer; limits and 'limited to 4 unless medical reason' apply to several implant codes

Residual bone support — Requirement that at least 50% of resting bone support must be present for certain prosthetic procedures

Requirement>= 50% resting bone support must be present

MeasurementMeasured remaining alveolar bone support (radiographic) used to determine eligibility

ConsequenceInsufficient support may lead to noncoverage for prosthetic replacement

New necessity — Documentation demonstrating new prosthetic necessity due to changes in tooth structure or failure of prior restoration

DocumentationNew necessity must be demonstrated with broad applied loss of tooth structure or failure of prior restoration

ExamplesReplacement prosthesis (D6252 and related) requires documentation of structural failure, new need, and bone support

ActionInclude clinical narrative and imaging to substantiate new necessity for replacement

Remaining bone support — Measured remaining alveolar bone support; at least 50% required in some cases

MeasureRemaining alveolar bone support — at least 50% required where specified

Applies toCertain crown/bridge and implant prosthesis coverage lines

Provider actionDocument percentage and supporting X‑rays in the record

Per-member frequency limits — Notations such as '1 per lifetime', 'per 12 months', 'per 24 months', 'per 60 months'

Frequency examples1 per lifetime, per 12 months, per 24 months, per 60 months are common per‑member limits

ActionCodes list their specific per‑member frequency; claims must honor those limits or include medical necessity documentation

Provider tipCheck the code line for exact per‑period language before billing

Medical necessity / X-Ray — 'X‑Ray required - medical necessity' indicates radiographic images and clinical justification must be present

RequirementX‑ray and medical necessity documentation required where policy states 'X‑Ray required - medical necessity'

ExamplesD7471–D7473 and other surgical/excision codes explicitly note X‑ray/medical necessity

ActionAttach supporting radiographs and clinical justification to pre‑service or claim documentation