CurrentPremera BluecrossPolicy N/A

2025 ADA Code List for Microsoft Plans (dental codes and pre-determination requirements)

A payer-specific ADA code list indicating for Microsoft employer-group dental benefits which ADA codes require dental review or pre-determination, what documentation is required, and code classification (Preventive, Basic, Not covered, Orthodontia, etc.). Affects providers submitting dental claims for members under Premera Microsoft plans.

Policy Summary

PayerPremera Bluecross

Policy2025 ADA Code List for Microsoft Plans (dental codes and pre-determination requirements)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse the list or code_check tool to confirm whether a code is marked 'Yes' for dental review/pre-determination and submit required documentation (narrative, diagnosis, treatment plan, imaging) when indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

part 1document part

multiplepre-D required

severalnot covered

keylegend

varieddocumentation types

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.

Per-code Coverage Criteria and Notes

Selected code coverage criteria (partial)

Examples of coverage stances and documentation rules from the list:

D0320 — Temporomandibular joint arthrogram; Dental Review Or Pre-D = NZA; Documentation Required = Not covered under dental. If submitting under medical, submit diagnosis and/or narrative (Medical Policy 2.01.21).

Code classed as Not covered

D0330 — Panoramic radiographic image; Dental Review Or Pre-D = Yes; Documentation Required = Provider must indicate if taken for orthodontia; Class = Preventive.

Pre-determination/dental review required

D0364 — Cone beam CT capture and interpretation with limited field of view; Dental Review Or Pre-D = Yes; Documentation Required = Diagnosis or narrative of condition (when submitted on dental claim) or follow Medical policy 9.02.503 when submitted under medical.

Pre-determination/dental review and narrative required

D0393 — Treatment simulation using 3D image volume; Dental Review Or Pre-D = NZA; Documentation Required = Not covered.

Explicitly Not covered

D0411 — HbA1c in‑office point of service testing; Dental Review Or Pre-D = NZA; Documentation Required = Not covered; Class = Not covered.

Not covered under dental

DO120 — Periodic oral evaluation (established patient); Dental Review Or Pre-D = N/A; Class = Preventive.

Routine preventive code — no pre‑D

Examples of coverage stance by code

Coverage class and notes extracted from ADA code list segment

DO801 — 3D intraoral surface scan direct; Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Imaging captured as not covered in this extract

D1206 — Topical application of fluoride varnish; Dental Review Or Pre‑D = N/A; Documentation Required = N/A; Class = Preventive.

Preventive class — no pre‑D

D1301 — Immunization counseling; Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Counseling codes frequently marked NZA / Not covered

Major/Complex restorative procedures

Major procedure review and documentation

D2520–D2663 (selected onlays/inlays, crowns and related major restorations) — Dental Review Or Pre‑D = Yes; Documentation Required = Chart notes, narrative, and imaging; Class = Major.

Prior dental review / pre‑determination required for major restorative codes

D2960–D2962 (veneers: direct/indirect labial veneers) — Dental Review Or Pre‑D = Yes; Documentation Required = Chart notes, narrative, and imaging; Class = Major.

Veneer procedures require chart notes, narrative and imaging for review

Not covered codes in excerpt

Codes explicitly marked as Not covered in this excerpt:

D5810 — Interim complete denture (maxillary). Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Not covered under dental

D5811 — Interim complete denture (mandibular). Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Not covered under dental

D5820 — Interim partial denture (maxillary). Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Not covered under dental

D5821 — Interim partial denture (mandibular). Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Not covered under dental

Per-code coverage entries (partial)

Per-code coverage and documentation guidance (partial list):

D5867 — Replacement of replaceable part of semi‑precision or precision attachment (male or female component). Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Explicitly not covered

D5899 — Unspecified removable prosthodontic procedure (by report). Dental Review Or Pre‑D = Yes; Documentation Required = Chart notes and a narrative; Class = Major.

Detailed chart notes and narrative required for review

D5911 — Facial moulage (sectional). Dental Review Or Pre‑D = Yes; Documentation Required = Description of procedure, chart notes; Class = Major/Medical.

Major/Medical prosthetic procedures require description and chart documentation

D6012 — Surgical placement of interim implant body for transitional use. Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Implant interim placement not covered under dental

Not covered / restricted items

Explicit not-covered or restricted codes noted in this segment

D6191 — Semi‑precision abutment placement. Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Marked Not covered

D6192 — Semi‑precision abutment placement (variant). Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Marked Not covered

D6253 — Provisional pontic — further treatment or completion of diagnosis necessary; Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Provisional pontic considered not covered

Documentation and pre-determination requirements

Codes requiring narrative or chart documentation and/or pre-determination

D6197 — Replacement of restorative material used to close an access opening of a screw‑retained implant supported prosthesis. Dental Review Or Pre‑D = YES; Documentation Required = Narrative; Class = Major.

Pre‑determination (Yes) and narrative required

D6199 — Unspecified implant. Dental Review Or Pre‑D = Yes; Documentation Required = If implant coverage is available, provide chart notes and a narrative; Class = Major.

Chart notes and narrative required when implant coverage is applicable

D7252 — Partial extraction for immediate implant placement (New Code 2025). Documentation Required = (not specified in extract); Class = Basic.

New code — follow documentation guidance where indicated

D7270 / D7272 — Tooth re‑implantation and/or stabilization (D7270) and tooth transplantation (D7272). Dental Review Or Pre‑D = Yes; Documentation Required = Pre‑accident state of tooth, description of procedure, chart notes, narrative, diagnosis as applicable; Class = Basic.

Partial coverage rules and submission criteria

Coverage classifications and special submission instructions (partial):

Orthognathic surgery codes (e.g., D7949, D7950, D7953, D7955) — Documentation Required = Description of procedure; chart notes; narrative; diagnosis as applicable; reference Medical policy Orthognathic Surgery (9.02.501).

Medical‑level documentation required for orthognathic procedures

TMJ‑related surgical codes (e.g., D7810–D7870 series) — Class = Not covered under dental; Dental Review Or Pre‑D = NZA; If submitting under the medical plan provide description of procedure, chart notes, narrative, and diagnosis; reference Medical policy Temporomandibular Joint Dysfunction.

Submit under medical with supporting documentation when appropriate

Dental Accident Review — For accident‑related facial/fracture and re‑implantation codes, Dental Accident Review may be required; providers should supply date and description of accident, X‑rays/photos, chart notes/office records; benefits may be payable under medical.

Accident submissions frequently reviewed for medical benefit eligibility

Coverage stance and required documentation

Coverage classes and documentation requirements noted per code; select services are explicitly Not covered under dental and some require submission under medical plan with supporting documentation.

D8692 — Replacement of lost or broken retainer (Deleted). Dental Review Or Pre‑D = NZA; Class = Not covered.

Deleted code and not covered

D9630 — Drugs or medicaments dispensed in the office for home use. Dental Review Or Pre‑D = NZA; Documentation Required = Description or narrative of drugs/medicaments when dispensed by dentist; Take‑home drugs are not covered; Class = Not covered.

Take‑home drugs not covered under dental

D9947–D9949, D9954–D9957 (custom sleep apnea appliances, OAT and related services) — Dental Review Or Pre‑D = Not covered under dental (N/C under dental); Documentation Required = If submitting under the medical plan, include description of procedure, chart notes, narrative, sleep study and diagnosis as applicable; Class = Not covered under dental — review medical DME/Medical Supplies/Prosthetics.

Sleep appliance services redirected to medical with required documentation

D8999 — Unspecified orthodontic procedure (by report). Dental Review Or Pre‑D = .; Documentation Required = Chart notes/narrative; may be reviewed for medical necessity for craniofacial anomalies per referenced Medical Policy.

ADA Procedure Codes and Coverage Status

Example ADA codes shown in listmixed

DO120	Periodic oral evaluation established patient
D0320	Temporomandibular joint arthrogram; including injection
D0364	Cone beam CT capture and interpretation with limited field of view less than one whole jaw

Imaging / Preventive DO codesmixed

DO704	3-D photographic image capture only
DO705	Extra-oral posterior dental radiographic image capture only
DO706	Intraoral occlusal radiographic image capture only
DO707	Intraoral periapical radiographic image capture only
DO708	Intraoral bitewing radiographic image capture only

Selected restorative/basic/major codesCPT

D2140	Amalgam one surface; primary or permanent
D2330	Resin-based composite; one surface, anterior
D2391	Resin-based composite one surface posterior
D2710	Crown resin-based composite (indirect)
D2799	Provisional crown - Not covered
D2991	Application of hydroxyapatite regeneration medicament per tooth - Not covered

Endodontic and related codesmixedCovered

D3332	Dental Review Or Pre-D = N/A; Class = Basic
D3333	Internal root repair of perforation defects; Class = Basic
D3346	Retreatment of previous root canal therapy anterior; Class = Basic
D3347	Retreatment of previous root canal therapy bicuspid; Class = Basic
D3348	Retreatment of previous root canal therapy molar; Class = Basic
D3351	Apexification/recalcification initial visit; Class = Basic
D3352	Apexification/recalcification interim medication replacement; Class = Basic
D3353	Apexification/recalcification final visit; Class = Basic
D3355	Pulpal regeneration initial visit; Class = Basic
D3356	Pulpal regeneration interim medication replacement; Class = Basic

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Not covered prosthodontics/interim and precision attachmentsmixedNot Covered

D5810	Interim complete denture (maxillary) — Not covered
D5811	Interim complete denture (mandibular) — Not covered
D5820	Interim partial denture (maxillary) — Not covered
D5821	Interim partial denture (mandibular) — Not covered
D5862	Precision attachment — Not covered
D5863	Overdenture complete maxillary — Not covered
D5864	Overdenture partial maxillary — Not covered
D5865	Overdenture complete mandibular/partial mandibular — Not covered

Examples of prosthodontic and maxillofacial codes (partial)mixedCovered

D5867	Replacement of replaceable part of semi-precision or precision attachment (male or female component); Documentation Required = Not covered; Class = Not covered
D5875	Modification of removable prosthesis following implant surgery; Class = Major
D5899	Unspecified removable prosthodontic procedure; by report; Documentation Required = Chart notes and a narrative; Class = Major
D5911	Facial moulage (sectional); Dental Review Or Pre-D = Yes; Documentation Required = Description of procedure, chart notes; Class = Major/Medical

Implant-related codes and deletions (partial)mixed

D6012	Surgical placement of interim implant body for transitional; Dental Review Or Pre-D = NZA; Documentation Required = Not covered; Class = Not covered
D6053	Deleted code (implant/abutment supported removable denture); marked NZA or Deleted
D6193	New Code - Replacement of an implant screw; Documentation Required = Not subject to a replacement limitation; Class = Major

Selected implant and abutment codes (partial)mixed

D6112	Implant/abutment supported removable denture for partially edentulous arch maxillary
D6113	Implant/abutment supported removable denture for partially edentulous arch mandibular
D6114	Implant/abutment supported fixed denture for edentulous arch maxillary
D6193	Replacement of an implant screw (new code)
D6191	Semi-precision abutment placement (marked Not covered)

Extractions and related surgical codesCPTCovered

D7140	Extraction, erupted tooth or exposed root
D7210	Extraction, erupted tooth requiring removal of bone and/or sectioning
D7252	Partial extraction for immediate implant placement (New Code 2025)

Lesion excision codes (medical overlap noted)mixedCovered

D7410	Excision of benign lesion up to 1.25 cm (Dental Review Or Pre-D = Yes)
D7440	Excision of malignant tumor lesion diameter up to 1.25 cm (Pre-D = Yes)

Oral surgery codes (partial)mixed

D7490	Class = Basic (listed in extract)
D7509	Marsupialization of odontogenic cyst; Dental Review Or Pre-D = Yes; Documentation Required: Description of procedure; chart notes, narrative; diagnosis as applicable Medical policy Orthognathic Surgery (9.02.501); Class = Basic

TMJ-related and not-covered dental codes (partial)mixedNot Covered

D7810	Open reduction of dislocation; Not covered under dental; if submitting under medical plan submit description, chart notes, narrative; reference Temporomandibular Joint Dysfunction
D7880	Occlusal orthotic device; Not covered under dental; if submitting under medical plan include documentation per TMJ policy

Orthodontia codes (new 2025 codes included)mixedCovered

D8070	Comprehensive orthodontic treatment of the transitional dentition; Dental Review Or Pre-D = Yes; Class = Routine Orthodontia/ Medical Orthodontia
D8091	Comprehensive orthodontic treatment with orthognathic surgery; New Code 2025; Dental Review Or Pre-D = Yes; Class = Routine Orthodontia/ Medical Orthodontia

Orthodontia codesmixed

D8210	Removable appliance therapy
D8220	Fixed appliance therapy
D8660	Pre-orthodontic treatment examination to monitor growth and development
D8670	Periodic orthodontic treatment visit
D8671	Periodic orthodontic treatment visit associated with orthognathic surgery (New Code 2025)
D8680	Orthodontic retention (removal of appliances, construction; and placement of retainer(s))
D8681	Removable orthodontic retainer adjustment
D8690	Orthodontic treatment (alternative billing to a contract fee)

Deleted codes and coverage notesmixedNot Covered

D8691	Repair of orthodontic appliance (Deleted)
D8692	Replacement of lost or broken retainer (Deleted) - Class = Not covered
D8693	Re-cement or re-bond fixed retainer (Deleted)
D8694	Repair of fixed retainers, includes reattachment (Deleted) - notes about medical necessity for craniofacial anomalies

Anesthesia, unspecified procedures, and related codesmixed

D8999	Unspecified orthodontic procedure; by report
D9120	Fixed partial denture sectioning
D9130	Temporomandibular joint dysfunction non-invasive physical therapies
D9210	Local anesthesia not in conjunction with operative or surgical procedures
D9211	Regional block anesthesia
D9212	Trigeminal division block anesthesia
D9215	Local anesthesia
D9219	Evaluation for moderate general anesthesia
D9222	Deep sedation/general anesthesia first 15 minutes
D9223	Deep sedation/general anesthesia each subsequent 15-minute

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Codes redirected to medical plan / Not covered under dentalmixedNot Covered

D9630	Drugs or medicaments dispensed in the office for home use - Not covered; take-home drugs not covered
D9947	Custom Sleep Apnea Appliance Fabrication and Placement - Not covered under Dental; review medical
D9948	Adjustment of Custom Sleep Apnea Appliance - Not covered under Dental; review medical
D9949	Repair of custom sleep apnea appliance - Not covered under Dental; review medical
D9954	Fabrication and delivery of oral appliance therapy (OAT) - Not covered under dental; submit under medical with documentation
D9955	Titration visit - Not covered under dental; submit under medical with documentation
D9956	Administration of home apnea test sleep - Not covered under dental; submit under medical with documentation
D9957	Screening for sleep related breathing disorders - Not covered under dental; submit under medical with documentation

Case management and teledentistry codesmixed

D9991	Dental case management addressing appointment compliance barriers - requires narrative
D9992	Dental case management care coordination - requires narrative
D9993	Dental case management motivational interviewing
D9994	Dental case management patient education to improve oral health literacy
D9995	Teledentistry synchronous; real-time encounter - Not covered
D9996	Teledentistry asynchronous; stored and forwarded - Not covered
D9999	Unspecified adjunctive - requires chart notes/narrative

inv-28: authorization color key

Color keyRed = Authorization/documentation requirements; Blue = Not covered services; Grey = Deleted codes

Usage noteUse this list or the code_check tool to confirm pre-determination (pre-D) or dental review requirements

ScopeApplies to the 2025 ADA Code List for Microsoft Plans (Premera) and referenced in the code legend

Prior Review, Submission Guidance and Documentation Requirements

Prior Authorization

Pre-determination / Dental review requirements

Pre-determination (pre-D) or dental review is required for many ADA codes — submit a pre-D when indicated to determine benefit applicability and to avoid denials. Use the plan's 2025 ADA code list or the code_check tool to confirm requirements; when multiple class listings exist, refer to benefit details or submit a pre-D. Provide chart notes, narrative, and imaging when requested.

Use code list or code_check to confirm Pre-D/dental review requirement.
If more than one class listed, refer to benefit details or submit a pre-D.
Chart notes, narrative, and imaging are commonly requested for restorative and major services.

Prior Authorization

Prior review required for specified major restorative codes

Certain major restorative and prosthodontic codes require prior review or pre-determination. Submit chart notes, narrative, and images for major inlays/onlays, veneers, crowns, and other major restorative services to support medical necessity and coverage.

Fields and Flags Used in the Code List

inv-48: Dental Review or Pre-D

DefinitionIndicates whether a pre-determination (pre-D) or dental review is required before the service is performed/paid; entries include 'Yes', 'N/A', 'NZA' or blank

How to confirmUse this ADA code list or the code_check tool to confirm if pre-D/dental review is required for a specific code

ImplicationCodes marked 'Yes' require dental review/pre-determination and specified documentation (narrative, diagnosis, treatment plan)

inv-49: Documentation Required

DefinitionSpecifies narrative, diagnosis, treatment plan, pathology or operative reports, or other documents that must be submitted with the claim or pre-determination

ExamplesPeriodontal charting, photos, radiographic imaging, chart notes, and narratives are listed as documentation requirements for specific codes (e.g., D4381, D5899, D5911)

Policy Summary

PayerPremera Bluecross

Policy2025 ADA Code List for Microsoft Plans (dental codes and pre-determination requirements)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

D5862 — Precision attachment; by report. Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Precision attachments not covered

D5863–D5865 — Overdenture (complete/partial) codes. Dental Review Or Pre‑D = NZA; Documentation Required = Not covered; Class = Not covered.

Overdentures marked Not covered

D6193 — Replacement of an implant screw (new code). Documentation Required = Not subject to a replacement limitation; Class = Major.

Replacement limitation note applies

Accident-related cases require pre‑accident details and clinical documentation

Unspecified orthodontic procedures require narrative and may be considered medically necessary in select cases

D8210–D8690 (Orthodontia codes) — Documentation Required = Limits apply: orthodontia treatment started prior to the Plan is limited to continuing monthly adjustments, retention, or phases performed while coverage is in effect; follow orthodontia documentation guidance for pre‑existing treatment limitations.

Orthodontia coverage limited by timing of treatment start and documentation

inv-29: Documentation requirement for major restorative codes

When requiredChart notes, narrative, and imaging are required when 'Dental Review Or Pre-D = Yes' for major restorative/onlay/inlay codes (examples: D2520, D2530, D2544, D2610, D2620, D2630)

Examples of affected codesD2520, D2530, D2544, D2610, D2620, D2630, D2642–D2651 (major/onlay/inlay family)

Action for providersSubmit complete chart notes, clinical narrative and radiographic imaging with pre-determination when flagged 'Yes'

inv-30: Replacement limitation note

Replacement limitationD6193 (replacement of an implant screw) is noted as not subject to a replacement limitation

Related guidanceOther implant replacement/repair codes include documentation and pre-determination guidance (see D6085, D6089, D6090 entries)

Provider actionFollow code-specific documentation notes for implant parts; verify replacement limits before submission

inv-31: Documentation requirement

Orthognathic surgery documentationDescription of procedure; chart notes; narrative; diagnosis as applicable for orthognathic surgery codes (per Medical policy Orthognathic Surgery 9.02.501)

Maxillofacial / prosthesis documentationDescription of procedure; chart notes; narrative; diagnosis as applicable for complex maxillofacial and prosthetic procedures (examples: D5911, D5923–D5929)

When submitting to medicalIf code is Not covered under dental (NZA/N/A), submit diagnosis and narrative to medical per referenced medical policy

Examples: D2520, D2530, D2544, D2610–D2644, D2650–D2651 — Dental Review / Pre-D = Yes; Documentation: chart notes, narrative, and imaging.

Repairs and unspecified restorative procedures may require narrative and imaging to determine coverage.

Documentation Required

Documentation and review for veneer/unspecified restorative codes

Veneers and unspecified restorative codes often require documentation to support the clinical need. Provide chart notes, narrative, and radiographic imaging when submitting these codes for review.

D2960, D2961, D2962 — Dental Review / Pre-D = Yes; Documentation: chart notes, narrative, and imaging (D2962 may list documentation specifics).
D2956 (removal of indirect restoration) — Repairs to crowns/bridges require documentation when performed ≥6 months after initial placement.

Prior Authorization

Pre-determination / Dental review for periodontal and certain surgical codes

Periodontal and select surgical codes may require dental review or pre-determination and supporting periodontal documentation. Provide periodontal charting, narrative, and photos (if available) to support procedures such as gingivectomy, crown exposure, and localized antimicrobial delivery.

D4210, D4211, D4212, D4230 — Dental Review / Pre-D = Yes; Documentation: periodontal charting, narrative, photo (if available).
D4381 (localized antimicrobial delivery) — Dental Review / Pre-D = Yes; Documentation: periodontal charting, narrative, photo (if available).

Documentation Required

Pre-determination / Documentation for prosthodontic repairs

Prosthodontic repairs and unspecified prosthodontic procedures often require narrative documentation describing the repair, including original placement date for dentures and detailed chart notes.

D5511, D5512 — Dental Review / Pre-D = Yes; Documentation: narrative including original denture placement date.
D5899 — Dental Review / Pre-D = Yes; Documentation: chart notes and narrative for unspecified removable prosthodontic procedure.

Documentation Required

Periodontal review/documentation expectations

For periodontal reviews, include full periodontal assessment details to expedite review and support medical necessity determinations.

Include probing depths, bleeding on probing, mobility, furcation involvement, and charting supporting diagnosis and treatment plan.
Photos and narratives are requested when available to corroborate clinical findings.

Prior Authorization

Prior review / pre-determination indicators (partial)

Certain services indicate prior review or pre-determination is required. Review the ADA code list and submit chart notes, narratives, and imaging when the code is marked 'Yes' for Dental Review or Pre-D to avoid denial.

Implant-related codes (D6085, D61089, D61090, etc.) — many are Dental Review / Pre-D = Yes; Documentation: chart notes, narrative, and imaging.
D6199 (unspecified implant) — Dental Review / Pre-D = Yes; Documentation: chart notes and narrative if implant coverage is available.

Prior Authorization

Accident-related tooth re-implantation/transplantation pre-determination

Accident-related re-implantation, transplantation, and major facial fracture reductions require Dental Accident Review. Submit pre-accident tooth state, detailed procedure description, chart notes, narrative, and diagnosis; medical benefits may apply — include medical submission when appropriate.

D7270, D7272 — Dental Review / Pre-D = Yes; Documentation: pre-accident state of tooth, procedure description, chart notes, narrative, diagnosis as applicable.
D7610–D7640 (open/closed reduction of maxilla/mandible) — Dental Review / Pre-D = Yes; Documentation: pre-accident tooth state, procedure description, chart notes, narrative; Dental Accident Review required; benefits may be payable under medical.

Note

Dental Accident Review / Medical Submission Guidance and TMJ — Medical submission instructions

For dental services that may be covered under the medical plan (TMJ-related procedures), submit the service under medical when indicated. Provide CPT code(s), diagnosis, detailed description of service, chart notes, and narrative consistent with Medical Policy 2.01.21 (Temporomandibular Joint Dysfunction). Many TMJ surgical codes are not covered under dental and require submission to medical for review.

Examples: D0310, D0320–D0322, D7810–D7850 series — Not covered under dental or NZA; if submitting to medical, include diagnosis and narrative per Medical Policy 2.01.21.
D9130 (non-invasive TMJ physical therapies) — Dental Review / Pre-D = Yes; Documentation: CPT code, diagnosis, and description of service for review.

Documentation Required

Orthognathic Surgery — Documentation requirement

Orthognathic surgery and related bone grafting have specific documentation requirements. When codes indicate medical policy referral, submit description of procedure, chart notes, narrative, and diagnosis as applicable to support coverage under Medical Policy Orthognathic Surgery (9.02.501).

D7949, D7950, D7953, D7955 — Documentation: description of procedure; chart notes; narrative; diagnosis as applicable; reference Medical Policy Orthognathic Surgery (9.02.501).
Sinus augmentation codes (D7951, D7952) — Dental review required to determine if medical benefits apply; submit to medical when appropriate.

Documentation Required

Orthodontia pre-existing treatment limitation and medical necessity documentation

Orthodontia coverage is limited for treatment started prior to plan enrollment — continuing monthly adjustments and retention are allowed, but new phases started before coverage are generally excluded. For medically necessary orthodontia (e.g., craniofacial anomalies), submit comprehensive documentation.

Orthodontia started prior to plan: limited to continuing monthly adjustments, retention, or new treatment phases performed while coverage is in effect.
If claiming 'medically necessary' orthodontia for congenital anomalies, provide description of procedure, chart notes, narrative, diagnosis, and imaging as applicable; reference Medical Policy Orthodontic Services for Treatment of Congenital Anomalies (9.02.500).
D8999 (unspecified orthodontic) — Dental Review / Pre-D = Yes; Documentation: no review for routine orthodontia, but medical-case submissions require full documentation.

Billing Rule

Redirect of sleep appliance services to medical plan

Sleep appliance and oral appliance therapy services are generally not covered under dental and should be redirected to the medical plan (Medical Supplies, Equipment, Prosthetics / DME). When submitting under medical, include description of procedure, chart notes, narrative, sleep study, and diagnosis per Medical Policy Sleep Disorder Management (Services Reviewed by Carelon, 10.01.524).

D9947–D9949 (custom sleep apnea appliance fabrication/adjust/repair) — Not covered under dental; review and submit under medical plan for DME/Supplies/Prosthetics.
D9954–D9956 (oral appliance therapy, titration, home apnea testing) — Not covered under dental; if submitted to medical, include sleep study and diagnosis as applicable.

Medical submissionWhen code is Not covered under dental, documentation required for medical submission may include diagnosis and narrative per referenced medical policy

inv-50: Class

DefinitionBenefit classification assigned to each ADA code (examples: Preventive, Basic, Major, Orthodontia, Not covered)

UsageClass determines coverage applicability and whether further pre-determination or benefit detail review is required

ExamplesD1206 = Preventive; D4341 = Basic; many implant/prosthodontic codes = Major

inv-51: NZA

Meaning of NZAUsed as an entry value in the list to indicate services that are Not covered under dental (often with instruction to review/submit under medical)

ExamplesD0320, D0321, DO801, and several preventive/counseling codes are listed with Dental Review Or Pre-D = NZA and Documentation Required = Not covered

Provider actionIf marked NZA, verify medical plan coverage and submit required medical documentation when applicable

inv-52: Deleted code

DefinitionAnnotation indicating an ADA procedure code has been deleted as of a specific date (example: D1515 deleted 1/2019; D2941 deleted 1/1/2025)

ImplicationDeleted codes are shown as Grey in the legend and are not billable; refer to updated codes for replacement services

Examples in listD1515, D1525, D2941 cited as deleted in the code list

inv-53: Benefit classification (e.g., Preventive, Basic, Major, Not covered) as shown in the ADA code list.

DefinitionBenefit classification examples used in the ADA code list: Preventive, Basic, Major, Orthodontia, Not covered

PurposeUsed to determine applicable benefit coverage and member responsibility under the Plan

Example mappingD1110 = Preventive; D4341 = Basic; D2520 = Major

inv-54: Indicator whether a dental review or pre-determination is required (Yes/N/A/NZA).

Indicator valuesField values include: Yes (dental review/pre-D required), N/A, NZA (not covered under dental/submit to medical), or blank

How usedDetermines if pre-determination/dental review must be obtained prior to service or if medical submission is required

ExamplesD6197 = Yes; D6112 = N/A; D0320 = NZA

inv-55: Specifies clinical or administrative documentation required with claims or for pre-determination.

Typical required documentsChart notes, clinical narrative, radiographic imaging, procedure description, diagnosis, periodontal charting or photos as specified per code

Code-specific examplesD5899 and D5911 require chart notes and narrative/description of procedure; D6197 requires a narrative; D6199 requires chart notes and narrative if implant coverage is applicable

When to includeInclude required documentation with pre-determination requests or with claims when the code is flagged for documentation

inv-56: Indicates whether the code requires dental review or pre-determination (values include Yes, NZA, N/A or blank).

Flag valuesIndicates whether the code requires dental review or pre-determination: Yes, NZA, N/A, or blank

Operational effect'Yes' triggers prior dental review/pre-determination workflow; 'NZA' often indicates not covered under dental and may require medical submission

ExamplesD5899 = Yes; D6197 = Yes; D6112 = N/A; D0320 = NZA

inv-57: Benefit classification of the procedure such as Basic, Major, or Major/Medical.

Common benefit classesMajor, Major/Medical, Basic, Preventive, Not covered, Orthodontia

ExamplesD5911 = Major/Medical; D6085 = Major; D7140 = Basic; D1206 = Preventive

Use in adjudicationClass guides benefit payment and whether additional documentation or medical submission is required

inv-58: Dental Review Or Pre-D

Dental Review/Pre-D fieldIndicates whether a pre-determination (pre-D) or dental review is required; use list or code_check tool to confirm per code

Legend referenceCodes marked in Red denote authorization/documentation requirements; verify before providing service

Provider instructionSubmit required documentation (narrative, diagnosis, treatment plan) with pre-D requests for codes flagged 'Yes'

inv-59: Class

Class definitionCoverage class designation such as Major, Basic, Preventive, Not covered, Orthodontia

Decision useClass guides coverage determination and member cost-sharing

ExampleD6112 = Major; D4341 = Basic; D1351 = Preventive

inv-60: ADA CODE columns

Column mappingADA CODE columns: Column 1 = Description; Column 2 = Dental Review Or Pre-D; Column 3 = Documentation Required; Column 4 = Class

UseFollow column guidance when reading the ADA code list for required actions and documentation per code

inv-61: NZA / N/A / Yes flags

Flag meaningsNZA / N/A indicate not applicable or not available; 'Yes' indicates dental review or pre-determination is required per code entries

Operational noteNZA often corresponds with 'Not covered' and may require medical submission instead of dental billing

ExamplesD7951 = NZA (dental review required to determine medical benefits applicability); D8692 = NZA (deleted/not covered)

inv-62: Documentation Required / Dental Review Or Pre-D

Field purpose'Documentation Required' and 'Dental Review Or Pre-D' fields indicate whether pre-determination or supporting documents (chart notes, narratives, imaging, sleep studies) are required for review or coverage determination

ExamplesD5899 requires chart notes and narrative; D6197 requires a narrative; D9947–D9957 sleep appliance services require medical submission with sleep study results as applicable

Action for providersInclude specified documentation with pre-D requests or claims to avoid denials or requests for additional information

inv-63: Class

Definition'Class' assigns coverage classification to each code (examples: Orthodontia, Basic, Preventive, Not covered, Routine Orthodontia/Medical Orthodontia)

ExamplesD8210–D8690 cluster = Orthodontia class; D8692 deleted = Not covered

UseRefer to Class to determine benefit applicability and member cost-share