CurrentFidelis CarePolicy N/A

Supplemental Dental Benefits — 2025 benefit schedule

Defines the supplemental dental benefits, covered procedure codes, and frequency/periodicity limits that apply to Fidelis Care 2025 plan benefit packages (NY plans listed). Affects providers submitting dental services for members of the named plan packages.

Policy Summary

PayerFidelis Care

PolicySupplemental Dental Benefits — 2025 benefit schedule

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for listed CBCT and other codes that require prior approval before treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~100+listed dental procedure codes in excerpt

6/12/36/60common periodicity shown

CBCT D0364-D0368prior auth flagged codes

4 up / 2 lowimplant default limits

Some require reportreport-based services

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Periodicity

General coverage conditions and documentation requirements

Covered when billed with valid documentation and within stated periodicity limits and benefit allowances. Services must meet coding-specific periodicity and code-specific clinical conditions noted in this section.

ALL of the following

Procedure is billed with an appropriate CDT code and documentation that supports medical/dental necessity (operative report, radiographs, clinical findings).
Service does not exceed the procedure-specific periodicity or lifetime limit specified for the CDT code(s).
See code-specific entries for periodicity (e.g., D0120: once every 6 months; crowns: generally once per 60 months).
When applicable, documentation must demonstrate clinical thresholds (for example: at least 50% remaining tooth support for crown or restoration coverage; pocket depths >=5 mm and persistent inflammation for local delivery of antimicrobials).clinical criteria
Examples are listed in code descriptions (crowns, endodontics, periodontal therapies).
Services submitted more frequently than allowed periodicity must include a supporting clinical report justifying medical necessity (e.g., complications, acute change in condition).
When the policy notes provider, facility, or prior authorization requirements (e.g., cone beam CT codes D0364-D0367, certain surgical or implant-related codes), those requirements must be satisfied before coverage is approved.
Procedures that are excluded by code notes or the explicit exclusions list are not covered even if other criteria are met (see Exclusions).
When codes are listed as not allowed in combination or on the same date of service as specified codes, claims that violate those combination restrictions will be denied unless clinical justification is provided.
Replacement or repair services must meet replacement periodicity rules and minimum time-since-insertion requirements (for example, relines/rebases not covered within 6 months of placement; denture replacement periodicity).
Implant and implant-supported prosthesis coverage is subject to quantity limits and medical necessity documentation demonstrating why conventional prosthodontics are not appropriate.
Report-based or unspecified procedures (e.g., D0999, D3999, D4999, D6999, D9999) require a clinical report stating medical necessity and supporting documentation; coverage is determined on a case-by-case basis.
If an alternate (more costly) treatment is chosen by the patient, benefits may be limited to an allowance based on the standard covered service; patient is responsible for any difference in cost.
Services must conform to accepted standards of dental practice; investigational, experimental, duplicative, or non-therapeutic services are not covered.
Provider enrollment or specialty restrictions apply where noted (for example, certain oral pathology services must be provided by an enrolled oral pathologist).

Covered CDT Codes and Frequencies

Diagnostic/Evaluation CodesCPTCovered

D0120	Periodic oral evaluation - established patient
D0140	Limited problem-focused evaluation - emergency
D0150	Comprehensive oral evaluation - new or established patient
D0160	Detailed and extensive oral evaluation - problem focused, by report
D0180	Comprehensive periodontal evaluation
D0190	Screening of patient
D0191	Assessment of patient

Radiology/Imaging CodesCPTCovered

D0210	Intraoral - complete series of radiographic images
D0220	Intraoral - periapical first image
D0230	Intraoral - periapical each additional image
D0240	Intraoral - occlusal film
D0250	Extra-oral - 2D projection radiographic image
D0251	Extra-oral - posterior dental radiographic image
D0270	Bitewing - single radiographic image
D0272	Bitewings - two radiographic images
D0273	Bitewings - three radiographic images
D0274	Bitewings - four radiographic images

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Other Diagnostic/Pathology/Teledentistry CodesCPTCovered

D0391	Teledentistry - asynchronous store and forward
D0460	Pulp vitality tests
D0470	Diagnostic casts
D0474	Accession of tissue, gross and microscopic surgical
D0485	Consultation with preparation of slides from biopsy material
D0502	Other oral pathology procedure, by report
D0701	Panoramic image capture only
D0703	2D photographic image capture only
D0706	Intraoral-occlusal image capture only
D0707	Intraoral-periapical image capture only

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Preventive & Restorative CodesCPTCovered

D1110	Prophylaxis - adult
D1206	Topical application of fluoride varnish
D1208	Topical application of fluoride - excluding varnish
D1320	Tobacco counseling for control and prevention of oral disease
D1354	Placement of caries arresting medicament - per tooth
D1355	Caries prevention medicament
D1999	Unspecified preventive procedure, by report
D2140	Amalgam - one surface, primary or permanent
D2150	Amalgam - two surfaces, primary or permanent
D2160	Amalgam - three surfaces, primary or permanent

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Restorative & Prosthodontic CodesCPTCovered

D2390	Resin-based composite crown, anterior
D2391	Resin-based composite - one surface, posterior
D2392	Resin-based composite - two surfaces, posterior
D2393	Resin-based composite - three surfaces, posterior
D2394	Resin-based composite - four or more surfaces, posterior
D2710	Crown - resin-based composite (indirect)
D2720	Crown - resin with high noble metal
D2721	Crown - resin with predominantly base metal
D2722	Crown - resin with noble metal
D2740	Crown - porcelain/ceramic

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Crowns - cast and metal crownsCPTCovered

D2781	crown - ¾ cast base metal
D2782	crown - ¾ cast noble metal
D2790	crown - full cast high noble metal
D2791	crown - full cast base metal
D2792	crown - full cast noble metal
D2794	crown - titanium and titanium alloys

Prefabricated/recementation proceduresCPTCovered

D2910	Re-cement or re-bond inlay/onlay/veneer/partial coverage restoration
D2915	Re-cement or re-bond for indirect fabricated
D2920	Re-cement or re-bond crown
D2928	Prefabricated porcelain/ceramic crown
D2931	Prefabricated stainless steel crown - permanent tooth
D2932	Prefabricated resin crown
D2933	Prefabricated stainless steel crown with resin window

Posts, cores, and related restorative adjunctsCPTCovered

D2950	Core build-up, includes any pins when needed
D2951	Pin maintenance - per tooth
D2952	Cast post and core as part of crown
D2953	Each additional non-directly fabricated post
D2954	Prefabricated post and core as part of crown
D2955	After extraction (not with endodontic therapy)
D2957	Each additional prefabricated post
D2971	Additional procedures to make new crown under existing partial denture framework

Pulpal and endodontic proceduresCPTCovered

D3110	Pulp cap direct (not including final restoration)
D3120	Pulp cap indirect (not including final restoration)
D3220	Therapeutic pulpotomy (not including final restoration)
D3230	Pulpal therapy (resorbable filling) - anterior, primary
D3240	Pulpal therapy (resorbable filling) - posterior, primary
D3310	Endodontic therapy, anterior (not including final restoration)
D3320	Endodontic therapy, premolar (not including final restoration)
D3330	Endodontic therapy, molar (not including final restoration)
D3331	Anesthesia for root canal; non-surgical access
D3332	Incomplete endodontic therapy

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Endodontic surgical and related proceduresCPTCovered

D3351	Apexification/recalcification - initial visit
D3352	Apexification/recalcification - interim medication replacement
D3353	Apexification/recalcification - final visit
D3410	Apicoectomy - anterior
D3421	Apicoectomy - premolar (first root)
D3425	Apicoectomy - molar (first root)
D3426	Apicoectomy - each additional root
D3430	Retrograde filling - each root
D3450	Root amputation - per root
D3470	Intentional reimplantation

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Periodontal surgical and grafting proceduresCPTCovered

D4210	Gingivectomy/gingivoplasty - 4+ contiguous teeth per quadrant
D4211	Gingivectomy/gingivoplasty - 1-3 contiguous teeth per quadrant
D4212	Gingivectomy for access for restorative procedure
D4240	Gingival flap procedure with root planing - 4+ teeth per quadrant
D4241	Gingival flap procedure with root planing - 1-3 teeth per quadrant
D4245	Apically positioned flap
D4249	Clinical crown lengthening - hard tissue
D4260	Osseous surgery - 4+ teeth per quadrant
D4261	Osseous surgery - 1-3 teeth per quadrant
D4266	Guided tissue regeneration - resorbable barrier

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Non-surgical periodontal and maintenance proceduresCPTCovered

D4322	Splint - intra-coronal; natural teeth or prosthetic crowns
D4323	Splint - extra-coronal; natural teeth or prosthetic crowns
D4341	Periodontal scaling and root planing - 4+ teeth per quadrant
D4342	Periodontal scaling and root planing - 1-3 teeth per quadrant
D4346	Scaling full mouth for moderate or severe gingival inflammation
D4355	Full mouth debridement to enable comprehensive periodontal evaluation and diagnosis
D4381	Local delivery of antimicrobial agents via controlled release vehicle, per tooth
D4910	Periodontal maintenance procedures
D4920	Unscheduled dressing change
D4999	Unspecified periodontal procedure, by report

Prosthodontics — dentures and partials, repairs and rebasesCPTCovered

D5110	Complete denture - maxillary
D5120	Complete denture - mandibular
D5130	Immediate denture - maxillary
D5140	Immediate denture - mandibular
D5211	Maxillary partial denture - resin base
D5212	Mandibular partial denture - resin base
D5213	Maxillary partial denture - cast metal framework with resin base
D5214	Mandibular partial denture - cast metal framework with resin base
D5225	Maxillary partial denture - flexible base
D5226	Mandibular partial denture - flexible base

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Covered CDT Codes (partial list from document)CPTCovered

D5511	repair broken base of complete denture, mandibular
D5512	repair broken base of complete denture, maxillary
D5520	replace missing or broken teeth — complete denture (each tooth)
D5611	repair resin base removable partial denture, mandibular
D5612	repair resin base removable partial denture, maxillary
D5621	repair cast partial framework, mandibular
D5622	repair cast partial framework, maxillary
D5630	repair or replace broken retentive/clasping material (each tooth)
D5640	replace broken teeth (each tooth)
D5650	add tooth to existing partial denture

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Covered CDT Codes with periodicity and descriptionsmixedCovered

D6210	Denture adjustment (listed with periodicity group)
D6211	Denture-related code (listed with periodicity group)
D6212	Denture-related code (listed with periodicity group)
D6214	Denture-related code (listed with periodicity group)
D6240	High noble metal fused to pontic - porcelain
D6241	Pontic - porcelain fused to base metal
D6242	Pontic - porcelain fused to noble metal
D6243	Pontic - porcelain fused to titanium/titanium alloy
D6245	Prosthodontics fixed, pontic - porcelain/ceramic
D6250	Pontic - resin with high noble metal

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Report-based codesCPT

D6999

Unspecified adjunctive procedure - requires report to support medical necessity

Fixed partial prosthesis maintenancemixedCovered

D6930	Re-cement or re-bond fixed partial denture
D6980	Repair of fixed partial denture

Extractions and surgical removalsmixedCovered

D6999	Unspecified adjunctive procedure, base on report
D7111	Extraction, coronal remnant - primary tooth
D7140	Extraction, erupted tooth or exposed root
D7210	Surgical removal of erupted tooth requiring bone removal and/or sectioning
D7220	Removal of impacted tooth - soft tissue
D7230	Removal of impacted tooth - partial bony
D7240	Removal of impacted tooth - complete bony
D7241	Removal of impacted tooth - complete bony with unusual complications
D7250	Surgical removal of residual tooth roots (cutting procedure)
D7251	Coronectomy - intentional partial tooth removal

Access, biopsies, alveoloplastymixedCovered

D7280	Surgical access to unerupted tooth
D7282	Mobilization of erupted or malpositioned tooth
D7283	Placement of device to manage eruption of impacted tooth
D7285	Incisional biopsy of oral hard tissue (bone, tooth)
D7286	Incisional biopsy of oral soft tissue
D7287	Collection of exfoliative cytological sample
D7288	Brush biopsy
D7290	Surgical repositioning of teeth
D7310	Alveoloplasty with extractions - 4+ teeth per quadrant
D7311	Alveoloplasty with extractions - 1-3 teeth per quadrant

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Vestibuloplasty and excisionsmixedCovered

D7340	Vestibuloplasty - ridge extension (secondary epithelialization)
D7350	Vestibuloplasty - ridge extension
D7410	Radical excision - lesion up to 1.25 cm
D7411	Excision of benign lesion >1.25 cm
D7412	Excision of benign lesion, complicated
D7413	Excision of malignant lesion up to 1.25 cm
D7414	Excision of malignant lesion >1.25 cm
D7415	Excision of malignant lesion, complicated

Tumor/cyst removal and relatedmixedCovered

D7440	Excision of malignant tumor - up to 1.25 cm
D7441	Excision of malignant tumor - >1.25 cm
D7450	Removal of odontogenic cyst or tumor - up to 1.25 cm
D7451	Removal of odontogenic cyst or tumor - >1.25 cm
D7460	Removal of nonodontogenic cyst or tumor - up to 1.25 cm
D7461	Removal of nonodontogenic cyst or tumor - >1.25 cm
D7465	Destruction of lesion(s) by physical/chemical means

Exostosis/torus and other osseous proceduresmixedCovered

D7471	Removal of exostosis - per location
D7472	Removal of torus palatinus
D7473	Removal of torus mandibularis
D7485	Surgical reduction of osseous tuberosity
D7490	Radical resection of maxilla or mandible

Cyst management, abscess, foreign body, ostectomymixedCovered

D7509	Marsupialization of odontogenic cyst
D7510	Incision and drainage of intraoral abscess - soft tissue
D7511	Incision and drainage intraoral - complicated
D7520	Incision and drainage of extraoral abscess - soft tissue
D7521	Incision and drainage extraoral - complicated
D7530	Removal of foreign body from mucosa/skin/subcutaneous alveolar tissue
D7540	Removal of reaction-producing foreign body, musculoskeletal system
D7550	Partial ostectomy/sequestrectomy for removal of non-vital bone
D7560	Maxillary sinusotomy for removal of tooth fragment or foreign body

Fractures, reductions, facial bone surgerymixedCovered

D7610	Maxilla - open reduction
D7620	Maxilla - closed reduction
D7630	Mandible - open reduction
D7640	Mandible - closed reduction
D7650	Malar and/or zygomatic arch - open reduction
D7660	Malar and/or zygomatic arch - closed reduction
D7670	Alveolus stabilization of teeth, closed reduction splinting
D7671	Alveolus - open reduction, possibly with tooth stabilization
D7680	Facial bones - complicated reduction with fixation and multiple surgical approaches
D7710	Maxilla - open reduction (repeat group)

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Additional facial trauma procedures and TMJmixedCovered

D7730	Mandible - open reduction
D7740	Mandible - closed reduction
D7750	Malar and/or zygomatic arch - open reduction
D7760	Malar and/or zygomatic arch - closed reduction
D7770	Alveolus stabilization of teeth, open reduction splinting
D7771	Alveolus closed reduction stabilization of teeth
D7780	Facial bones - complicated reduction with fixation and multiple approaches
D7810	Open reduction of dislocation
D7820	Closed reduction dislocation
D7830	Manipulation under anesthesia

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TMJ surgery and arthroscopymixedCovered

D7850	Surgical discectomy, with/without implant
D7852	Disc repair
D7854	Synovectomy
D7856	Myotomy
D7858	Joint reconstruction
D7860	Arthrotomy
D7865	Arthroplasty
D7870	Arthrocentesis
D7872	Arthroscopy - diagnostic
D7873	Arthroscopy - surgical lavage/lysis of adhesions

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Anesthesia and sedationmixedCovered

D7880	Occlusal orthotic device, base on report
D7899	Unspecified TMD treatment, base on report
D7910	Suturing of minor wounds up to 5 cm
D7920	Skin graft
D7940	Osteoplasty for orthognathic deformities
D7941	Osteotomy - mandibular rami
D7943	Osteotomy - mandibular rami with bone graft
D7944	Osteotomy - segmented or subapical
D7945	Osteotomy - body of mandible
D7946	LeFort I (maxilla - complete)

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Bone grafting, sinus augmentation, frenectomy, soft tissuemixedCovered

D7950	Osseous/graft of mandible or maxilla - autogenous or nonautogenous
D7951	Sinus augmentation (covered only for implants)
D7952	Sinus augmentation vertical (requires prior auth)
D7953	Bone replacement graft for ridge preservation - per site (covered only for implants)
D7961	Buccal/labial frenectomy
D7962	Lingual frenectomy
D7970	Excision of hyperplastic tissue - per arch
D7971	Excision of pericoronal gingiva
D7972	Surgical reduction of fibrous tuberosity
D7980	Sialolithotomy

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Emergency, anesthesia assessment, sedation, facility calls, prosthesis maintenancemixedCovered

D7990	Emergency tracheotomy
D7991	Coronoidectomy
D7997	Removal of appliance (not placed by removing dentist); includes archbar removal
D7998	Intraoral fixation device - not fracture
D7999	Unspecified oral surgery procedure, base on report
D9110	Palliative treatment of dental pain - per visit
D9120	Sectioning of fixed partial denture
D9219	Evaluation for deep sedation/general anesthesia
D9222	Deep sedation/general anesthesia - first 15 minutes
D9223	Deep sedation/general anesthesia - each additional 15 minutes

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Service/visit codes and periodicityCPTCovered

D9311	Consultation by a medical health care professional (periodicity: 1 per week)
D9410	Home or extended care facility call (periodicity: 1 per day per patient)
D9420	Hospital or ambulatory surgical center call (periodicity: 3 per 1 week per patient)
D9430	Office visit for observation - no other services performed (periodicity: 4 per 12 months per patient)
D9440	Office visit - after regularly scheduled hours (periodicity: 1 per day per patient); not covered when billed with D0120, D0140, D0150, D0160, D0180, D9110, D9310 or D9430
D9610	Therapeutic drug injection, single drug (periodicity: 1 per date of service)
D9612	Therapeutic drug injection, two or more drugs (periodicity: 1 per date of service)
D9911	Application of desensitizing resin medicament (periodicity: 1 per tooth per 24 months)

Denture, occlusal guard, and related maintenance codesCPTCovered

D9930	Treatment of postoperative complications (periodicity: 1 per date of service)
D9932	Cleaning and inspection of removable complete denture, maxillary (periodicity: 1 per 24 months for D9932-D9935)
D9933	Cleaning and inspection of removable complete denture, mandibular (periodicity: 1 per 24 months for D9932-D9935)
D9934	Cleaning and inspection of removable partial denture, maxillary (periodicity: 1 per 24 months for D9932-D9935)
D9935	Cleaning and inspection of removable partial denture, mandibular (periodicity: 1 per 24 months for D9932-D9935)
D9942	Occlusal guard adjustment or reline (periodicity: 1 per 24 months)
D9944	Occlusal guard—hard appliance, full arch (periodicity: 1 per 12 months for D9944-D9946)
D9945	Occlusal guard—soft appliance, full arch (periodicity: 1 per 12 months for D9944-D9946)
D9946	Occlusal guard—hard appliance, partial arch (periodicity: 1 per 12 months for D9944-D9946)

Teledentistry, case management, and adjunctive codesCPTCovered

D9951	Occlusal adjustment - limited (periodicity: 1 per 24 months)
D9990	Certified translation or sign-language services per visit (periodicity: 2 per day per patient)
D9991	Dental case management - addressing barriers to appointment adherence (used for audio-only teledentistry; may be billed as stand-alone)
D9995	Teledentistry - synchronous; real-time encounter (periodicity: 1 per date of service for D9995-D9996)
D9996	Teledentistry - asynchronous; store-and-forward information (periodicity: 1 per date of service for D9995-D9996)
D9997	Dental case management - members with special healthcare needs (not covered when billed with D9430; 1 per date of service for D9410, D9420, D9997)
D9999	Unspecified adjunctive procedure, report required (periodicity: based on report of medical necessity)

Prophylaxis frequency — D1110

CodeD1110

Allowed frequencyOnce every 6 months per patient

NotesNot allowed same date as certain other visit codes where specified (see policy)

Panoramic / full series frequency

CodesD0210, D0330, D0701, D0709

Allowed frequencyOnce every 36 months per patient

NotesPeriodic grouping shown as one (D0210, D0330) or (D0701, D0709) every 36 months

Crown frequency

Code rangeCrown codes D2710–D2794 (examples D2710, D2740, D2750, D2794)

Allowed frequencyOnce every 60 months per tooth per patient

Clinical exceptionsException allowed if additional tooth loss requires new appliance construction, or extensive tooth structure loss with ≥50% remaining bone support; third molars excluded unless medically necessary

Restorative frequency for fillings

CodesAmalgam D2140–D2161; Composite D2330–D2335, D2391–D2394

Allowed frequencyOnce every 24 months per tooth/surface per patient

GroupingThese codes share a combined 24‑month periodicity group (one of listed codes per tooth/surface)

Minimum remaining tooth support

RequirementMinimum remaining tooth/bone support of ≥50%

Applies toNumerous restorative, pulpal and endodontic procedures (e.g., D3110-D3120, D3220, D3310-D3330 series)

DocumentationClinical documentation must demonstrate remaining support to substantiate coverage

Common restorative periodicity

Common interval60 months per tooth for many crown and core-related codes

ExamplesD2710, D2720–D2722, D2740, D2750–D2753, D2780–D2794; D2950/D2952/D2954 series per 60 months

ExceptionsClinical exceptions apply when additional tooth loss or extensive structural loss documented

Denture replacement periodicity

Codes/ServicesComplete and partial dentures (e.g., D5110, D5120, D5211, D5212) replacement per arch

Allowed frequencyOnce every 96 months (8 years) per arch per patient

NotesImmediate dentures and related grouped codes follow same 96‑month periodicity; repairs/adjustments have separate, shorter limits

Periodontal surgical periodicity

CodesMany periodontal surgical procedures (e.g., D4240, D4241, D4260, D4261)

Allowed frequencyOnce every 36 months per quadrant for listed periodontal surgeries

NotesSome periodontal procedures (D4245, D4277) require prior authorization; non-surgical SRP (D4341/D4342) have 24‑month intervals

Periodicity limits examples

Common periodicities (examples)1 per lifetime; 1 per 12 months; 1 per 24 months; 1 per 60 months; 1 per 96 months; D7870 every 6 months

ContextExact periodicity is shown per code in the schedule; examples above reflect typical limits across categories

ImplicationProviders must check code-specific periodicity before billing to avoid frequency denials

Implant quantity caps

Default implant quantity capUp to 4 implants in the maxilla (upper) and 2 implants in the mandible (lower)

ExceptionsMay exceed limits if a documented medical reason is provided; prior authorization may be required for quantities beyond limits

Applies toSurgical placement codes D6010/D6013 and many implant-supported appliance/abutment/crown codes (D6055–D6067, D6110–D6113)

D6081 sequencing

CodeD6081

Sequencing restrictionsNot covered on same date of service as D1110 or D4910; not covered on same date and same quadrant as D4241 or D4342

Allowed frequencyOnce per 12 months per patient

Remaining alveolar bone support

Requirement≥50% remaining alveolar bone support required

Applies toCoverage for many prosthodontic, restorative and endodontic procedures when documenting extensive structural loss

DocumentationClinical records and supporting x‑rays/pathology as indicated must demonstrate remaining bone support

Periodicity examples

Examples of periodicity terms1 per lifetime; 1 per 12 months; 1 per 24 months; specified counts per 60 months; D7870 every 6 months

Coding implicationEach code entry shows the exact periodicity; follow code-level rule for billing and coverage

Report-based itemsSome codes are 'base sa ulat' (report-based) and require medical statement/pathology or x‑rays per listing

Periodicity limits exact

Exact periodicity presentationExact periodicity is specified per code (examples: 1 per date of service; 1 per 12 months; 1 per 24 months)

Multiple allowancesSome services have multiple allowed units per interval (e.g., D0220 three per 6 months, D0230 4 per date of service)

Provider actionConfirm the code-specific periodicity prior to submission to prevent denials for frequency

Prior Authorization, Documentation & Billing Rules

Note

Benefit package verification

Verify the member's benefit package and applicable cost-share before providing or billing services. Refer to the member's Evidence of Coverage and the member ID card to confirm eligibility, benefit package, and remaining available benefits; benefit coverage and limits (including periodicity and quantity limits) apply per the member's plan and date of service.

Benefit verification required prior to treatment or submission.
Authorization or eligibility confirmation does not guarantee payment.

Prior Authorization

Prior Authorization Required — CBCT

Certain cone beam CT (CBCT) codes require prior authorization. Services submitted without required prior authorization may be denied.

Affected codes include D0364, D0365, D0366, D0368 (prior authorization required).
D0367 is covered only for implant-related indications (authorization may still be required).

Prior Authorization

Prior Authorization Required — Periodontal & Grafting

Some periodontal and grafting procedures require prior authorization. Claims for report-based or prior-authorization codes submitted without the required documentation may be denied.

Examples include D4245 (apically positioned flap) and D4277 (free soft tissue graft) — prior authorization required.
Unspecified procedure codes (e.g., D4999) require a statement of medical necessity and supporting report.

Billing Rule

Implant and Implant‑Supported Appliance Limits

Implant and implant-supported appliance services have quantity and periodicity limits and may require medical necessity documentation. Payment is limited by lifetime/periodicity rules and numeric limits; exceptions require documentation of medical necessity.

Surgical implant placement (D6010, D6013): 1 per tooth per lifetime; limited to 4 upper and 2 lower implants unless medical reason documented.
Connector/bar and many implant-supported components (D6055, D6056–D6064, D6110–D6113, D6191–D6192, etc.) have lifetime or 96-month/60-month periodicity limits and the same 4-up/2-down limit unless medical reason documented.
Unspecified implant procedures (D6199) are paid based on report and statement of medical necessity.

Billing Rule

Periodic Replacement & Prosthesis Periodicity Limits

Periodic replacement limits apply to many fixed and removable prosthodontic codes (commonly 60 months) and certain implant-supported components commonly use 96-month periodicity. Prior authorization may be required for exceptions or replacements sooner than the periodicity allows.

Many prosthodontic codes (e.g., D6210–D6252, D6545, D6240–D6253) follow a 60‑month periodicity for replacement.
Complete and removable implant-supported prostheses (D6110–D6113, D6110/D6112 pairs) typically follow a 96‑month periodicity.
Replacements or new appliances earlier than the listed periodicity require clinical justification and prior authorization.

Billing Rule

Implant‑Supported Removable Prosthesis Periodicity

Implant‑supported removable prostheses and related components have 96‑month periodicity and are subject to the same numeric limits (4 upper, 2 lower) unless a medical reason is documented and prior authorized.

Examples: D6110–D6113 removable prosthesis periodicity = 96 months.
Quantity limits: limited to 4 upper and 2 lower implants/components unless medical necessity documented.

Billing Rule

Peri‑Implant Maintenance Sequencing & Frequency

Peri‑implant maintenance and related procedures have sequencing and frequency restrictions. Follow stated periodicity when billing maintenance codes to avoid denials.

D6081 (peri-implant maintenance) limited to once per 12 months.
Attachment replacement/adjustment and recementation codes (D6090–D6096, D6091–D6094, D6092–D6093) have 12‑month, 24‑month, or longer periodicity as specified.

Billing Rule

Provider / Group Restriction

Provider/group restriction: Certain services are not allowed when performed by the same provider or group as indicated; check the policy notes for codes with provider restrictions.

Example: Apexification/apicoectomy and related codes (D3351–D3353, D3450, D3470) are limited to one lifetime per tooth and are not allowed if performed by the same provider or provider group for related codes.

Denial Risk

Frequency / Recency Restriction

Frequency/recency restrictions: Services billed within restricted intervals (e.g., replacements or recementation within specified months) may be denied if periodicity rules are not met.

Example: Crowns recementation D2920 limited to once every 24 months and not within 12 months of placement for the same tooth.
Relines, soft liners, and other prosthetic maintenance codes have specified 'not within X months' rules (commonly 6–24 months).

Documentation Required

Report‑Based Services Require Documentation

Report‑based services and unspecified codes (e.g., D3999, D4999, D5899, D5999, D6190, D6199) require a supporting report and a statement of medical necessity. Failure to submit required reports, pre‑ and post‑op imaging, or pathology will likely result in denial.

Unspecified or 'base sa ulat' codes: submit full clinical report and statement of medical necessity.
D6190 (radiographic/surgical implant index), D6199 (unspecified implant), D5899/D5999 (unspecified prosthetic/maxillofacial) — documentation-based payment.

Documentation Required

Documentation Should Support Extensive Loss / Medical Necessity

Documentation should support extensive loss of tooth structure, construction of a new appliance, or medical necessity for exceptions to periodicity or quantity limits. Clinical notes must justify replacement or fabrication of appliances outside normal limits.

For fixed prosthodontic replacements within periodicity, documentation must show extensive tooth structure loss, fracture, or >=50% remaining bone support criteria as applicable.
When more than the numeric implant limits are requested, provide medical rationale and supporting records.

Documentation Required

Pathology Report, Pre‑Op Imaging & Medical Necessity

Pathology reports, pre‑operative imaging (x‑rays), and medical necessity statements are required for many surgical, tumor/cyst, resection, torus removal, and other operative procedures to be considered for payment.

Procedures requiring pathology report and medical necessity statement include D7410–D7415, D7440–D7441, D7450–D7461, D7472–D7473, D7490, and similar codes (base on policy notes).
Pre-operative x‑rays required for torus removal, radical resection, and many incision/drainage or cyst/tumor procedures.

Denial Risk

Prior Authorization & Documentation — Payment Considerations

Approvals and authorizations do not guarantee payment. Payment decisions are based on member eligibility on the date of service, dental record documentation, satisfaction of policy limits and periodicity, required prior authorizations, and remaining available benefits.

Lack of required prior authorization, missing documentation, or exhausted benefits may result in denial.
Prior authorization must be obtained before treatment for listed codes; retrospective authorization does not ensure payment.

Step Therapy

Step therapy: no step therapy sequences are specified in this section; follow any plan-level step therapy requirements if they apply elsewhere in plan documents.

If step therapy rules exist for a given service, they will be listed in the applicable policy or Evidence of Coverage.

Definitions and Policy Terms

Periodicity definition

DefinitionPeriodicity = The allowed frequency for a given procedure as specified per code

InterpretationStated as intervals (months/years) or lifetime allowances in each code entry

Provider actionFollow code-specific periodicity when submitting claims

Covered for implants

Covered when billed for implantsSome codes (e.g., D0367, D0350, D7953) are covered only when billed for implant-related services

ExamplesD0350 coverage limited to implant use; D0367 covered only for implants; D7953 bone replacement graft for ridge preservation covered only for implants

ImplicationUse correct implant-related billing to qualify these codes for coverage

Minimum remaining tooth support

RequirementAt least 50% remaining tooth support/bone required for coverage

Applies toSeveral restorative and endodontic codes (e.g., pulpal/endodontic therapy, core build-up, crowns) and prosthodontic replacements

DocumentationClinical records and x‑rays must document remaining support

Third molar exclusion

ExclusionThird molars (wisdom teeth) are excluded from coverage for many crown and prosthetic codes

ExceptionCovered only when medically necessary with documentation

Applies toCrown code groups D2710–D2794 and many prosthodontic replacement rules

Implant placement (D6010, D6013)

CodesD6010, D6013

LimitSurgical implant placement limited to one lifetime per patient for listed codes; default quantity limits apply (4 upper, 2 lower)

NotePrior authorization may be required for quantities beyond default limits

Base sa ulat / report-based

DefinitionBase sa ulat / report-based: coverage depends on submitted clinical report and statement of medical necessity

ExamplesD6999, D6999, D5899, D6199, D5999 and select excision/tumor codes are 'base sa ulat' and require supporting reports

Provider actionSubmit required reports, pathology and pre-op x‑rays where indicated to substantiate coverage

Extensive loss of tooth structure

ConditionExtensive loss of tooth structure may justify prosthetic construction or replacement

RequirementDocumentation must demonstrate extensive structural loss and at least 50% remaining alveolar bone support

ImpactIf documentation is insufficient, replacement/new appliance may be denied if periodicity not met

Periodicity term examples

Periodicity term examples'1 per lifetime' and numeric months/years indicate the repeat allowance for each code (e.g., 1 per 12 months, 1 per 24 months, 1 per 60 months)

ApplicationFollow the exact code entry for permitted frequency; some codes show counts (e.g., two per lifetime) or multiple per interval

Provider actionCheck code‑level periodicity before billing to ensure compliance

Base sa ulat term

RequirementPayment consideration for some procedures requires submission of clinical report, medical necessity statement or pathology report

ExamplesExcision, tumor/cyst removal, torus removal, radical resection and other report-based codes

ConsequenceAbsent required documentation these services may be denied

Date of completion of treatment — definition

DefinitionDate of completion of treatment: the date when treatment is finished and may be billed (e.g., delivery date for removable dentures, final crown cementation, final root canal filling)

UsageUsed to determine billing/completion for prosthesis and final restorations

ReferenceSee policy for exact code entries that reference completion date for periodicity calculations

Policy Background

Background: this document enumerates the Fidelis Care supplemental dental benefits for 2025, listing covered CDT procedure codes, their descriptions, and applicable periodicity limits. It includes diagnostic, preventive, radiographic, restorative, periodontal, prosthodontic and oral surgery codes and highlights certain procedural requirements such as prior authorization for selected cone beam CT codes and documentation requirements for report‑based or exceptional services.

Revision History

2025Policy issueLatest

Published Fidelis Care Supplemental Dental Benefits schedule for 2025 outlining covered CDT codes, periodicity limits, prior authorization requirements, and documentation expectations.

Policy Summary

PayerFidelis Care

PolicySupplemental Dental Benefits — 2025 benefit schedule

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for listed CBCT and other codes that require prior approval before treatment.

SourceLink

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