Prior authorization required for many onlays/crowns

Numerous onlay, crown and other major restorative codes in the Exhibit list indicate Authorization Required = Yes; providers must obtain prior authorization before performing these services (examples include D2542–D2544, D2643–D2644, D2740, D2750–D2753, D2790–D2792).

• Examples with Authorization Required = Yes: D2542, D2543, D2544, D2643, D2644, D2740, D2752, D2753, D2790, D2791, D2792

Authorization required for specified crown, prosthodontic and periodontic services

Prior authorization is required for many crown, select prosthodontic and certain periodontic services; obtain authorization when the code line shows Authorization Required = Yes (for example D2752, D2753, D2790–D2792, D2931, and many denture codes).

• Authorization examples: D2752, D2753, D2790, D2791, D2792, D2931, D5110, D5120, D5130

Authorization required for many prosthetic and maxillofacial prosthetic codes

Authorization (prior approval) is required for many removable and fixed prosthodontic and maxillofacial prosthetic codes; obtain prior authorization and submit required documentation when Authorization Required = Yes (examples include D5110, D5120, D5130, D5213–D5214, D6210–D6242).

• Examples: D5110, D5120, D5130, D5140, D5211–D5214, D6210–D6242

Prior authorization required for many oral/maxillofacial procedures

Several oral/maxillofacial and unspecified oral surgery codes require prior authorization; documentation submitted with authorization requests must include narrative of medical necessity and may include pre-operative X‑rays, photos or models as specified.

• Authorization examples: D7730, D7740, D7810, D7820 and unspecified oral surgery entries (Authorization Required = Yes)
• Documentation: narrative of medical necessity, pre-op X‑ray(s), photos/models where listed

Authorization required for certain crowns and onlays (60‑month limits / 3+ crowns)

Authorization is required for specified crown and onlay codes, frequently when those services are subject to the 60‑month per patient per tooth benefit interval and for quantities of three or more crowns (e.g., authorization required for three or more D2931 stainless steel crowns).

• Codes cited with 60‑month limits and Authorization Required = Yes: D2752, D2753, D2790, D2791, D2792
• Authorization trigger: three or more prefabricated crowns (D2931) requires authorization

Prior authorization and limits for dentures and prostheses

Certain prosthodontic and maxillofacial prosthetic services require prior authorization or are limited by benefit intervals (for example, one complete denture per arch per 60 months); providers must obtain authorization when the code entry indicates Authorization Required = Yes and submit required documentation such as prior placement date and narrative of medical necessity.

• Examples: D5110/D5130 limited to one per 60 months per arch; D5110/D5120 list Authorization Required = Yes and require narrative of medical necessity, pre‑op X‑rays, and prior placement date

Obtain authorization or prepayment review when indicated

Many listed codes require authorization or prepayment review; providers must obtain authorization where the code line shows 'Authorization Required = Yes' or when prepayment review is specified (examples include D6999 and multiple oral surgery and prosthodontic codes).

• Examples: D6999 (Authorization Required = Yes); oral surgery codes D7220–D7260 and others note authorization or prepayment review

Check per‑code authorization field before requesting prior authorization

Authorization is specified per code in the Exhibits; some codes explicitly show Authorization Required = No (for example D0120, D1110, D4341, D4342, D4355), so verify the code line and obtain prior authorization only when the code indicates 'Yes'.

• Authorization Not Required examples: D0120 (No), D1110 (No), D4341 (No), D4342 (No), D4355 (No)

Adhere to frequency limits for space maintainers and sealants

Benefit limitations restrict frequency of certain services — for example, space maintainers are limited to one per lifetime (and re‑cement/re‑bond limited to one per 6 months), and sealants are limited to one per two years per tooth; billing outside these frequencies risks denial.

• Space maintainer: One per lifetime; re‑cement/re‑bond space maintainer: One per 6 months per patient
• Sealants: Limited to one per two years per tooth

Include required pre‑operative X‑rays with authorization/claim

Pre‑operative radiographs are required documentation for many prosthetic and restorative codes; include the specified pre‑op X‑ray(s) with prior authorization requests and claims when the code line lists 'Documentation Required = Pre‑operative X‑ray'.

• Examples: Onlay/crown codes (D2542–D2544, D2752, D2753, D2790–D2792) list 'Pre‑operative x‑ray' as required documentation

Pre‑operative X‑ray required for many crown codes

Many crown and restorative codes explicitly require a pre‑operative X‑ray; ensure the pre‑op radiograph listed on the code line is submitted with the authorization or claim (examples include D2752, D2753, D2790, D2791, D2792).

• Code examples requiring pre‑op X‑ray: D2752, D2753, D2790, D2791, D2792

Provide narrative of medical necessity and prior placement date for denture services

For some prosthodontic services providers must submit a narrative of medical necessity and the prior placement date when applicable (for example, complete denture codes D5110 and D5120 require narrative of medical necessity and prior placement date).

• D5110/D5120 documentation: Narrative of medical necessity, pre‑op X‑ray(s), and prior placement date

Submit perio charting and pre‑op X‑rays for periodontic procedures

Periodontal procedures require perio charting and pre‑operative X‑rays; include periodontal charting demonstrating bone loss and pocket depths greater than 4 mm and the pre‑op radiographs specified on the code line (examples: D4211, D4240, D4263).

• Documentation must show bone loss and pockets > 4 mm for many periodontal grafts and osseous procedures
• Codes listing required documentation include D4211, D4240, D4263, D4264

Provide all required documentation for prosthodontic and maxillofacial prosthetic services

Pre‑operative X‑rays, prior placement date (if applicable), and a narrative of medical necessity are required documentation for many prosthodontic and maxillofacial prosthetic services; include all items listed on the code line when requesting authorization or submitting claims.

• Examples: Maxillofacial fixed prosthetic codes (D6210–D6212) list pre‑operative X‑ray(s) and prior placement date as required documentation
• Many removable prosthodontic entries (D5110 series) require narrative of medical necessity and pre‑op X‑rays

Include narrative of medical necessity and imaging; provide pathology report when indicated

Many surgical and adjunctive services require a narrative of medical necessity and pre‑operative X‑rays; certain procedures also require pathology reports when indicated (for example, D7460 lists a pathology report requirement).

• Surgical codes with narrative and imaging requirements: D7730, D7740, D7810, D7820 (narrative of medical necessity and pre‑op X‑rays)
• Pathology report required for removal of cysts/tumors: D7460/D7461 (pathology report listed)

Submit study models/OrthoCad and X‑rays for orthodontic records and appliance placement

Orthodontic initial appliance placement and records require study models or OrthoCad and X‑rays; include these items when submitting authorization or documentation (codes D8080 and D8660).

• D8080/D8660 documentation: Study models or OrthoCad and X‑rays

Periodontal documentation must show bone loss and pockets >4 mm

Pre‑operative X‑rays and periodontal charting that document bone loss and pockets greater than 4 mm are required for many periodontal procedures; include the specified pre‑op radiographs and charting with the claim or authorization (applies to codes such as D4210, D4263, D4273).

• Periodontal documentation requirement: pre‑op X‑ray(s) and perio charting demonstrating bone loss and pockets > 4 mm

Ensure clinical documentation supports periodontal and denture claims

Pre‑operative X‑rays and periodontal charting must document bone loss and pockets greater than 4 mm for many periodontal procedures; denture services require narrative of medical necessity and prior placement date when listed on the code line.

• Examples: D4341/D4342 documentation: pre‑op X‑ray(s) and perio charting; D5110/D5120 require narrative of medical necessity and prior placement date

Narrative of medical necessity and imaging commonly required; pathology reports as specified

Many procedures require a narrative of medical necessity and pre‑operative X‑rays; certain surgical pathology codes specifically require pathology reports (e.g., removal of cysts/tumors listing pathology report).

• D6999 documentation: narrative of medical necessity and pre‑op X‑ray(s)
• D7450/D7451/D7460/D7461: pathology report required where indicated

Provide pathology reports for cyst/tumor removals when required

Removal of cysts or tumors codes require pathology reports when indicated; include the pathology report for codes such as D7450, D7451, D7460 and D7461 as specified on the code lines.

• Pathology report requirement cited for D7450, D7451, D7460, D7461

D6999 requires description, narrative of medical necessity, and pre‑op X‑rays

D6999 (fixed prosthodontic procedure, by report) requires a description of the service, a narrative of medical necessity, and pre‑operative X‑ray(s); include all items when requesting authorization or submitting the claim.

• D6999 documentation: Description of service, narrative of medical necessity, pre‑op X‑ray(s)

Submit pre‑op X‑rays and perio charting for D4341/D4342

Pre‑operative X‑rays and periodontal charting are required documentation for periodontal scaling and root planing codes D4341 and D4342; include these with claims to meet documentation requirements.

• D4341/D4342 documentation: pre‑op X‑ray(s) and perio charting

Denial risk: one comprehensive oral evaluation per lifetime and radiograph frequency limits

Comprehensive oral evaluation is limited to one per lifetime; radiograph reimbursements are limited to a single complete series per 36 months — billing more frequently than these limits risks denial.

• Benefit limits: One comprehensive oral evaluation per lifetime; One of (D0210, D0277, D0330) per 36 months

Denial risk: temporal and code‑sequence restrictions (e.g., 6‑month rule)

Certain codes are temporally restricted or disallowed in sequence; for example, some services are not allowed within 6 months of D2954 and some restorative/post-core codes are not allowed within specified series — review temporal restrictions to avoid denials.

• Example: Not allowed within 6 months of D2954 (D2915 and related entries).

Lifetime frequency denial risk for prefabricated crowns

One of the prefabricated crown group (D2930, D2932, D2933, D2934) is limited to one per lifetime per tooth; billing more than the lifetime limit or billing without required authorization when three or more crowns are provided risks denial.

• One of D2930/D2932/D2933/D2934 per lifetime per tooth; authorization required for three or more D2931

Do not bill prophylactic extraction without medical necessity (not covered)

Prophylactic extraction — removal of an asymptomatic tooth or a tooth free from pathology — is not a covered benefit; submitting claims without medical necessity documentation for such extractions may result in denial.

• Prophylactic removal of asymptomatic tooth or tooth free from pathology is explicitly excluded

Denial risk: prophylactic extraction not covered without medical necessity

Claims for prophylactic extractions of asymptomatic teeth lack coverage; ensure extractions are medically necessary and supported by documentation to avoid denial.

• Prophylactic removal of asymptomatic tooth or tooth free from pathology is not covered and may be denied

Authorization and narrative required for D9630 and D9999

Adjunctive by‑report codes D9630 and D9999 require prior authorization and a narrative of medical necessity (and for D9630, the name and amount of drug administered); failure to supply the required narrative and specifics may lead to denial.

• D9630 documentation: Name of drug/amount and narrative of medical necessity
• D9999 documentation: Description of service and narrative of medical necessity

Get authorization for 3+ prefabricated stainless steel crowns (D2931)

Authorization is required when three or more prefabricated stainless steel crowns (D2931) are provided; obtain prior authorization before performing three or more crowns to avoid denial.

• Authorization trigger: three or more D2931 prefabricated stainless steel crowns

Obtain authorization for crowns/onlays billed under 60‑month limits

Authorization is required for many onlay and crown codes when they are subject to the 60‑month per patient per tooth limit; verify authorization for codes billed under the 60‑month benefit interval (examples include D2752, D2753, D2790–D2792).

• Codes with 60‑month interval and Authorization Required = Yes: D2752, D2753, D2790, D2791, D2792

Obtain authorization for denture replacement/exceeding frequency limits

Authorization is required when replacement or initial denture services exceed frequency limits (for example, one of D5110 or D5130 per 60 months per arch); ensure authorization and required documentation are obtained for denture replacements beyond the benefit interval.

• D5110/D5130: limited to one per 60 months per arch; authorization and narrative of medical necessity required when limits are exceeded

Coverage exclusion: prophylactic extractions require medical necessity to be covered

Prophylactic removal of an asymptomatic tooth or a tooth free from pathology is excluded from coverage; lack of medical necessity documentation for extractions may result in denial.

• Exclusion applies across extraction code entries; ensure extractions are medically necessary with supporting documentation

Authorization/prepayment review risk for impacted tooth removal and incision/drainage

Impacted tooth removals and incision/drainage services may be subject to authorization or prepayment review; perform pre‑authorization as required and include pre‑op X‑rays and narrative of medical necessity to reduce denial risk (codes such as D7220–D7250 and D7510/D7511 are noted).

• Examples: D7220–D7250 and D7510/D7511 have authorization/prepayment review requirements and list pre‑op X‑rays and narrative of medical necessity