Premera Bluecross ADA Code List Coverage Update

Coverage rules (partial)

Representative coverage rules and requirements observed within this portion of the code list:

Codes labeled 'Class = Preventive' or 'Preventive/Basic' are generally covered subject to benefit details

Codes with 'Dental Review Or Pre-D = Yes' require pre-determination/dental review and supporting documentation such as diagnosis, narrative, or operative report

Some codes are explicitly 'Not covered' and should not be billed for reimbursement

Deleted codes are indicated and should not be used

Per-code criteria (JSON-encoded nodes)

Per-code coverage class and documentation rules (excerpt):

D1310 — Not covered; Documentation Required = Not covered; Class = Not covered

D1351 — Covered; Dental Review Or Pre-D = N/A; Documentation Required = N/A; Class = Preventive

D2510 — Covered with criteria; Dental Review Or Pre-D = Yes; Documentation Required = Preoperative X-rays and narrative describing existing restorations, tooth surface, prep and seat dates, and prior inlay/onlay/crown dates; Class = Major

D2950 — Covered with criteria; Documentation Required = Preoperative X-rays and narrative; Dental Review/Pre-D indicated for related restorative review; Class = Major

D2991 — Not covered; Documentation Required = Not covered; Class = Not covered

D3320 — Covered with criteria; Dental Review Or Pre-D = Yes; Documentation Required = X-rays and narrative; Class = Basic/Major

Coverage criteria and documentation requirements (selected codes)

Coverage stance and required documentation by code within these chunks:

Endodontic therapy (D3320, D3330) — Dental Review Or Pre-D = Yes; Documentation Required = X-rays and narrative

Retreatment codes (D3346, D3347) — Dental Review Or Pre-D = Yes; Documentation Required = Date of initial root canal and if <12 months then chart notes, X-rays, and narrative

Unspecified endodontic (D3999) — Dental Review Or Pre-D = Yes; Documentation Required = Chart notes and/or narrative describing procedure performed

Periodontal surgical codes (D4210–D4240 range) — Dental Review Or Pre-D = Yes; Documentation Required = Periodontal charting, narrative, photos and periapical X‑rays as applicable

Osseous/grafting codes (D4263–D4268) — Dental Review Or Pre-D = Yes; Documentation Required = Periapical X‑ray, periodontal charting and/or narrative including pocket depths and osseous defects; name/type of biologic material required for D4265

Documentation-driven coverage criteria

Documentation and review requirements for coverage determination

D5630/D5640/D5650 — Documentation Required = Narrative including the date when the denture was originally placed

D5899/D5911/D5912 — Dental Review Or Pre-D = Yes for many maxillofacial/facial prosthesis codes; Documentation Required = Chart notes and narrative (narrative required for facial prostheses)

D6010/D6040 — Implant placement codes require Dental Review Or Pre-D = Yes; Documentation Required = Preoperative X‑rays, list of missing teeth, periodontal charting, chart notes, prognosis and full treatment plan

Pre-determination required for selected codes

Pre-determination (Dental Review Or Pre-D) rules

D6010 — Dental Review Or Pre-D = Yes; Documentation Required = Preoperative X‑rays, all missing teeth, periodontal charting, chart notes, prognosis of implant; full treatment plan

D5911 — Dental Review Or Pre-D = Yes; Documentation Required = Narrative (facial moulage/sectional)

D5993 (and similar complex prosthetic codes) — Dental Review Or Pre-D = Yes as indicated in prosthetics section

Per-code coverage determinations (sample)

Coverage and review rules for select ADA codes in this window:

D6067 — Covered with criteria; Dental Review Or Pre-D = Yes; Documentation Required = X‑rays, chart notes, periodontal status, list of all missing teeth, and list of existing bridgework/partials/dentures

D6081 — Covered with criteria; Dental Review Or Pre-D = Yes; Documentation Required = Periodontal charting and/or narrative and/or photograph

D6198 — Not covered; Documentation Required = Not covered; Class = Not covered

D6095 — Deleted 1/1/2025; do not use (entry shows deleted and prior narrative requirement)

Coverage classification and documentation nodes

Coverage classification and documentation expectations for listed ADA codes in this excerpt.

D6940 — Not covered (Class = Not covered)

D6793 — Part of Primary procedure; Dental Review Or Pre-D = N/A; Documentation Required = N/A

D6612–D6615 — Major class; Dental Review Or Pre-D = Yes for D6612 (example); Documentation Required = Preoperative X‑rays, narrative describing restorations/decay, prep and seat dates, prior inlay/onlay dates if applicable

Per-code coverage criteria

Per-code coverage indicators and documentation requirements shown; many codes require pre-determination and specific supporting documentation.

D7650/D7660/D7670/D7671 — Dental Review Or Pre-D = Yes; Documentation Required = Pre‑ and post‑op X‑rays of teeth involved, office records/chart notes, any third‑party information, condition of teeth prior to the accident

D7880/D7881/D7899 — Occlusal orthotic and TMD device codes: Dental Review Or Pre-D = Yes; Documentation Required = Name/type of appliance and materials used, diagnosis with narrative of signs/symptoms, treatment plan (or CPT/diagnosis for unspecified TMD)

D7939 — Not covered; Documentation Required = Not covered

Per-code coverage stance and documentation

Coverage classes and documentation requirements for listed ADA codes in WA and AK employer group plans.

D8999 — Unspecified orthodontic procedure: Dental Review Or Pre-D = Yes; Documentation Required = Chart notes and a narrative to substantiate the reported service

D9230 — Not covered; Documentation Required = Not covered

D9947 — Custom sleep apnea appliance fabrication and placement: Dental Review Or Pre-D = Yes; Documentation Required = Diagnosis, narrative of signs/symptoms, treatment plan and sleep study (Review Under Medical)

ADA Procedure Codes and Coverage Status (by group)

Example evaluation codes (Preventive)CPTCovered

D0120	Periodic oral evaluation established patient
D0140	Limited oral evaluation problem focused
D0150	Comprehensive oral evaluation new or established patient

Cone beam CT / advanced imaging (require review)CPTCovered

D0364	Cone beam CT capture and interpretation with limited field of view less than one whole jaw
D0365	Cone beam CT capture and interpretation (one full dental arch - mandible)
D0383	Cone beam CT image capture with field of view of both jaws, with or without cranium

Cone beam CT / advanced imaging (require review)CPTCovered

D0364	Cone beam CT capture and interpretation with limited field of view less than one whole jaw
D0367	Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium
D0383	Cone beam CT image capture with field of view of both jaws, with or without cranium

Point-of-service tests (not covered)CPTNot Covered

D0411	HbAlc in-office point of service testing
D0412	Blood glucose level test in-office

Representative covered and not-covered ADA codes in excerptmixed

D1310	Detailed oral evaluation / Not covered
D1320	Tobacco counseling for the control and prevention of oral disease — Not covered
D1330	Oral hygiene instructions — Not covered
D1351	Sealant per tooth — Preventive
D2140	Amalgam one surface, primary or permanent
D2150	Amalgam two surfaces
D2330	Resin-based composite, one surface, anterior
D2510	Inlay metallic one surface — Major; documentation/pre-op X-rays required
D2950	Core buildup, including pins — Major; preoperative X-rays and narrative required
D3320	Endodontic therapy, anterior tooth — Basic/Major; Dental Review/Pre-D = Yes

Pulpal/restorative related codesCPTCovered

D2999	Unspecified restorative procedure, by report
D3110	Pulp cap direct (excluding final restoration)
D3120	Pulp cap indirect (excluding final restoration)

EndodonticsCPTCovered

D3320	Endodontic therapy, anterior tooth (excluding final restoration)
D3330	Endodontic therapy, molar (excluding final restoration)
D3346	Retreatment of previous root canal therapy, anterior
D3347	Retreatment of previous root canal therapy, molar

Periodontics and graftingCPTCovered

D4260	Osseous surgery, four or more contiguous teeth per quadrant
D4263	Bone replacement site in quadrant graft
D4273	Autogenous connective tissue graft procedure
D4274	Mesial/distal wedge procedure, single tooth

Periodontal maintenance and prostheticsCPTCovered

D4341	Periodontal scaling and root planing four or more teeth per quadrant
D4355	Full mouth debridement to enable comprehensive periodontal evaluation
D4910	Periodontal maintenance
D5110	Complete denture maxillary

Partial denture codesmixedCovered

D5212	Mandibular partial denture resin base (including retentive/clasping materials, rests, and teeth)
D5213	Maxillary partial denture cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)
D5214	Mandibular partial denture cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)

Implant and abutment related codesmixedCovered

D6010	Surgical placement of implant body: endosteal implant
D6058	Abutment supported porcelain/ceramic crown
D6067	Implant supported crown (high noble alloys)

Sample implant-related codesCPT | mixedCovered

D6067	Implant supported crown (high noble alloys)
D6081	Scaling and debridement in presence of inflammation or mucositis of single implant
D6104	Bone graft at time of implant placement

Pontic and crown codesCPT | mixedCovered

D6210	Pontic cast high noble metal
D6245	Pontic porcelain/ceramic
D6740	Retainer crown porcelain/ceramic

Inlay/onlay codesCPT | mixedCovered

D6608	Retainer onlay porcelain/ceramic, two surfaces
D6610	Retainer onlay cast high noble metal, two surfaces
D6634	Retainer onlay titanium

Retainer/onlay codes (examples)CPT | mixedCovered

D6612	Retainer onlay cast predominantly base metal, two surfaces
D6613	Retainer onlay cast predominantly base metal, three or more surfaces
D6614	Retainer onlay cast noble metal, two surfaces
D6615	Retainer onlay cast noble metal, three or more surfaces

Extraction codesCPT | mixedCovered

D7111	Extraction, coronal remnants primary tooth
D7140	Extraction, erupted tooth or exposed root
D7210	Extraction requiring removal of bone and/or sectioning of tooth
D7220	Removal of impacted tooth soft tissue

Facial/fracture reductionmixedCovered

D7650	Malar and/or zygomatic arch open reduction
D7660	Malar and/or zygomatic arch closed reduction
D7670	Alveolus closed reduction, may include stabilization of teeth
D7671	Alveolus open reduction, may include stabilization of teeth

Special/Deleted/Not covered codesmixedNot Covered

D7939	Indexing for osteotomy using dynamic robotic assisted or dynamic navigation
D8691	Repair of orthodontic appliance (deleted as of 01/2020)

Orthodontia maintenance/repairmixedCovered

D8696	Repair of orthodontic appliance maxillary (D9696 in doc)
D8703	Replacement of lost or broken retainer maxillary

Orthodontia codesCPTCovered

D8695	Removal of fixed orthodontic appliance for reasons other than completion of treatment
D9696	Repair of orthodontic appliance maxillary
D8697	Repair of orthodontic appliance mandibular
D8698	Recement or rebond fixed retainer maxillary
D8699	Recement or rebond fixed retainer mandibular

Not covered examplesCPTNot Covered

D9230	Inhalation of nitrous oxide/analgesia, anxiolysis - Not covered
D9630	Drugs or medicaments dispensed in the office for home use - Not covered
D9970	Enamel micro‑abrasion - Not covered

Occlusal guard / mouthguard codesCPT

D9944	Occlusal guard hard appliance, full arch
D9945	Occlusal guard soft appliance, full arch
D9941	Fabrication of athletic mouthguard - Not covered

Deleted codes

Deleted codes (examples)D5281 — deleted 01/2019; D6052 — deleted 01/2021; D6095 — Deleted 1/1/2025

ContextDeleted codes are shown in the list and should not be used for claims submission

Appeals noteFor deleted codes the entry may include prior documentation guidance (e.g., preparation/seat dates) — check benefit details

Documentation threshold

Common documentation thresholdPreoperative and current X-rays, chart notes, periodontal status, lists of missing teeth and existing bridgework/partials/dentures frequently required

Narrative requirementsNarrative describing restorations/decay, tooth surface, prep and seat dates and prior restoration dates for onlays/inlays/crowns

Procedure-specific itemsPhotos, operative reports, pathology reports, and treatment plans or sleep study (for sleep appliance) may be requested per code

Pre‑Determination, Documentation & Provider Guidance

Prior Authorization

Pre-determination / Dental review requirements (summary)

Pre-determination (pre-D) or dental review is required for many non-routine, major, surgical, implant, prosthodontic, orthodontic adjunct, sleep/apnea, TMJ/TMD, maxillofacial and select radiographic procedures. Submit a pre‑determination when the ADA code entry indicates Dental Review Or Pre-D = Yes or when benefit class/plan language is unclear. Use pre-D to confirm member benefits, coverage limitations, and any medical review needed (for example, selected sleep apnea appliances are reviewed under medical).

Submit pre-determination for codes listed with Dental Review Or Pre-D = Yes.
Provide full chart notes, narratives, and required imaging specified on the code list.
When multiple provider classes or employer group variants exist, check benefit details or submit pre‑D.

Documentation Required

Documentation expectations for select codes

Some codes require specific documentation to allow timely review and avoid delays or denials. Follow the code-specific documentation fields exactly when submitting a pre‑determination or claim.

Endodontics (e.g., D3320, D3330): X‑rays and narrative/chart notes describing diagnosis and treatment plan.
Inlays/onlays, crowns, retainer/onlay codes (e.g., D2510–D2663, D2712–D2721, D6612–D6615): Preoperative X‑rays, narrative describing existing restorations/decay/defects, tooth surface(s), prep and seat dates, and prior inlay/onlay or crown dates if applicable.
Implant crowns/abutments/repairs (e.g., D6067, D6082–D6083, D6094, D6197, D6199): X‑rays, periodontal status, chart notes, list of missing teeth and existing prostheses, and narrative describing need.
Periodontal procedures (e.g., D4210–D4240): Full periodontal charting, narrative, and photos when available; include periapical X‑rays as requested.
Oral surgery/trauma (e.g., D7261, D7270, D7670–D7680): Pre/post op X‑rays, accident description/third‑party info when applicable, and operative reports or chart notes.
Maxillofacial/facial prostheses (e.g., D5911–D5916, D5999): Chart notes and narrative; for medical‑class items include medical documentation when required.
Occlusal appliances/TMD (D7880–D7899, D9945–D9946): Name/type of appliance, materials used, diagnosis with signs/symptoms narrative, and treatment plan.
Sleep apnea oral appliances (D9947–D9956, D9953–D9954): Diagnosis, treatment plan, and sleep study or other medical documentation — these are reviewed under medical.

Denial Risk

Not covered procedures

Procedures or codes listed as Not Covered or explicitly marked 'Not covered' must not be billed as covered services; submission may be denied. Do not submit pre‑determination expecting coverage unless plan language differs.

Examples of Not Covered codes from the list include: D1310, D1320, D1321, D1330, D1354, D1355, D9230, D7939, D9961, D9970–D9973 (external/internal bleaching entries noted as Not covered).
Codes marked 'Deleted' should not be billed (observe deletion dates).

Prior Authorization

Pre-determination/Review requirements for select endodontic codes

Select endodontic codes require prior review — submit X‑rays and narratives as specified to support medical necessity and procedure details.

D3320, D3330 (initial endodontic therapy): X‑rays and narrative required; Dental Review Or Pre‑D = Yes.
D3331–D3333 (treatment of obstructions, incomplete therapy, internal root repair): Narrative/chart notes and X‑rays as applicable; Dental Review Or Pre‑D = Yes.
D3999 (unspecified endodontic): Chart notes and a narrative describing the procedure performed; Dental Review Or Pre‑D = Yes.

Prior Authorization

Pre-determination/Review for retreatment and regenerative endodontics

Retreatment and regenerative endodontic procedures require additional supporting documentation; early retreatments (<12 months) have heightened review requirements.

D3346–D3347 (retreatment of previous root canal therapy): Provide date of initial root canal. If retreatment occurs <12 months from initial therapy, submit chart notes, current and prior X‑rays, and a narrative describing reason for retreatment.
D3351–D3353 (apexification/recalcification): Narrative required; include clinical rationale and imaging when applicable.
D3355–D3356 (pulpal regeneration): Narrative and/or chart notes required; Dental Review Or Pre‑D = Yes.

Prior Authorization

Pre-determination required for selected implant procedures

Selected implant procedures require pre‑determination with specific supporting materials to verify need and plan for prosthetic integration.

D6067, D6082, D6083, D6094: X‑rays, chart notes, periodontal status, list of all missing teeth and existing bridgework/partials/dentures, and prep/seat dates when applicable.
D6081 (implant maintenance) and D6090–D6093 (repairs/re-cementation): Provide narrative/chart notes describing procedure, and photos or X‑rays when applicable.
D6199 (unspecified implant procedure): Chart notes and narrative required.

Prior Authorization

Preauthorization / Dental Review indicators

Certain services trigger medical review or preauthorization indicators; flagged items often require both dental and medical documentation.

Sleep apnea appliances (D9947–D9956 series): Reviewed under medical — include sleep study and medical treatment plan.
Major maxillofacial prostheses and facial prosthetics (D5911–D5916, D5999): May require medical justification; submit medical records where indicated.
Orthognathic surgery and complex facial reductions (D7650–D7680, D7940–D7946): Preoperative medical/operative reports and imaging required.

Denial Risk

Denial risks and deletions

Failure to provide required documentation or billing codes correctly increases denial risk or may lead to claim deletions. Follow code‑level directions and plan benefit language to reduce risk.

Missing required X‑rays, narratives, periodontal charting, or operative reports is a frequent cause for denial.
Billing deleted or not‑covered codes will result in denial or rejection; confirm current ADA code status and deletion dates.
Use precise procedure codes (avoid unspecified codes when a specific code exists) and include tooth numbers, surface counts, and dates where requested to avoid administrative denials.

Prior Authorization

Pre-determination requirements for oral surgery codes

Oral surgery codes with 'Dental Review Or Pre‑D = Yes' require imaging, narratives, and accident/third‑party documentation when applicable.

D7261 (primary closure of sinus perforation): Preoperative periapical or panoramic X‑ray plus chart notes or operative report.
D7270 (tooth re‑implantation/stabilization): If related to an accident, include date and description of accident, indication of workers' comp/third‑party, and photos/X‑rays.
D7283–D7295 series (eruption devices, temporary anchorage, bone harvest): Narrative and chart notes as specified for each code.

Prior Authorization

Pre-determination for orthodontic adjunct and grafting codes

Orthodontic adjuncts, retainers, and grafting codes may require prior review or be covered only under active orthodontia benefits. Document relationship to orthodontic treatment and include narratives when requested.

D8703–D8704 (replacement of lost/broken retainer): Covered only when member has orthodontia — check benefit class.
D7295–D7296 series (harvest of bone, corticotomy): Submit narrative and chart notes; note some corticotomy codes are Not covered.
D8999 (unspecified orthodontic procedure): Chart notes and narrative required.

Prior Authorization

Prior review required for select facial/maxillofacial procedures

Select facial and maxillofacial procedures require prior review and often cross into medical benefit territory; include medical records, operative reports, and pre/post‑op imaging as specified.

D5911–D5916, D5919, D5992–D5999 (facial/maxillofacial prosthesis and adjustments): Chart notes and narrative; for medical‑class items include medical justification.
D7650–D7680 and D7670–D7671 (malar/zygomatic/facial bone reductions and alveolus reductions): Pre/post op X‑rays, office records, chart notes, and third‑party information when applicable.

Documentation Required

Occlusal appliance and TMD device review

Occlusal appliances and TMD devices need detailed appliance specifications and clinical rationale to determine coverage and appliance type classification.

D7880 (occlusal orthotic device) and D7881 (adjustment): Submit the name/type of appliance, materials used, diagnosis narrative, and treatment plan to determine hard vs soft appliance and full vs partial arch coverage.
D7899 (unspecified TMD therapy): Provide CPT code, diagnosis, and detailed description of service; Dental Review Or Pre‑D = Yes.
Occlusal guard codes D9945–D9946: Confirm coverage per plan — many are N/A for pre‑D but require documentation when billed.

Denial Risk

Not covered code example

Some individual code examples are explicitly not covered — include these in submission checks to avoid processing denials.

Example not covered: D1310 (preventive palliative treatment) — listed as Not covered on the code list.
Example not covered: D9230 (inhalation of nitrous oxide/analgesia) — listed as Not covered.

Prior Authorization

Sleep apnea appliance review

Custom sleep apnea appliances and related OAT services are reviewed under the medical benefit; include sleep study data and medical treatment plan to support coverage.

D9947 (custom sleep apnea appliance fabrication and placement): Require diagnosis narrative, treatment plan and sleep study; Dental Review Or Pre‑D = Yes and Review Under Medical.
D9948–D9949 (adjustment/repair) and D9953–D9956 (reline, fabrication, HST administration, screening): Require diagnosis, treatment plan and sleep study or equivalent medical documentation.

Legend and Column Definitions

KEY

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

Use guidanceUse the code list or code check tool to confirm if pre‑determination (Pre‑D) or dental review is required

ScopeApplies to 2025 ADA Code List for Premera non‑individual employer groups (WA, AK)

Dental Review Or Pre-D / Documentation Required

Column: Dental Review Or Pre‑DIndicates whether pre‑determination or dental review is required (values: Yes / N/A / blank / Not covered)

Column: Documentation RequiredSpecifies clinical records required to support review (examples: narrative, diagnosis, operative report)

ActionIf entry = Yes, submit pre‑determination or supporting documentation as specified

Column key / legend

Column 1Description — ADA procedure description

Column 2Dental Review Or Pre‑D — indicates pre‑determination/review requirement

Column 3Documentation Required — specific supporting records to submit for review

Column 4Class — benefit/service classification (e.g., Preventive, Basic, Major, Review Under Medical)

Column definitions for the code list

ADA CODE (1)Description — short procedure name/definition

Dental Review Or Pre‑D (2)Flag indicating if pre‑determination/dental review is required (Yes/N/A/Not covered)

Documentation Required (3)Lists required documentation such as X‑rays, narratives, operative reports, chart notes

Class (4)Service classification used to determine benefit applicability (Preventive/Basic/Major/Review Under Medical)

Service classification

Service classification: PreventiveRoutine evaluations, prophylaxis, sealants; typically covered under preventive benefits

Service classification: BasicMinor restorative and palliative procedures; coverage depends on benefit details

Service classification: MajorComplex restorations, crowns, implants and prosthetics (Class = Major)

Service classification: Review Under MedicalAppliances such as custom sleep apnea devices require review under medical with diagnosis and sleep study

Specific records required for claims review

NarrativeDescription of condition, signs/symptoms and treatment rationale frequently required for dental review or appeals

Pre/postoperative X‑raysRequired for many restorative, implant and surgical codes to document need and treatment

Chart notes and periodontal chartingRequired for periodontal procedures, implant planning and some prosthetic services

Preparation and seat datesMay be requested for denture/partial claims when frequency or replacement is in question

Major

Class definitionClass = Major (used to designate complex restorative/prosthetic procedures)

ImplicationMajor procedures commonly require dental review or extensive documentation

ExamplesImplant crowns, implant maintenance, major fixed prosthodontics are classed as Major in the list

Documentation Required

DefinitionDocumentation Required = specific clinical records needed to support the procedure (e.g., narrative, X‑rays, operative reports)

Typical itemsX‑rays, narrative, chart notes, periodontal charting, photos, pathology/operative reports, prep/seat dates

When to submitSubmit documentation when code entry indicates 'Yes' for Dental Review/Pre‑D or when claim is appealed

Dental Review Or Pre‑D

DefinitionDental Review Or Pre‑D = indicator whether pre‑service review or pre‑determination is required (values: Yes / N/A / blank / Not covered)

Action required when 'Yes'Obtain and submit pre‑determination/dental review with required documentation prior to providing service

Values meaningN/A or blank indicates no pre‑determination required; 'Not covered' indicates service is not reimbursable

Documentation Required (table column definitions)

Table column: DescriptionProcedure name/brief description as listed in ADA code column

Table column: Dental Review Or Pre‑DIndicates if pre‑determination or dental review is required for that procedure

Table column: Documentation RequiredSpecifies the records to include when submitting for review or appeal

Table column: ClassDesignates benefit class (Preventive, Basic, Major, Review Under Medical)

Review Under Medical

Review Under MedicalIndicates the service (e.g., custom sleep apnea appliance) should be reviewed as a medical benefit and requires diagnosis, treatment plan and sleep study

When usedApplied to codes that cross dental/medical boundaries (sleep apnea appliance codes D9947–D9953 etc.)

Required documentationDiagnosis, narrative of signs/symptoms, treatment plan and sleep study as specified in the entry

Dental Review Or Pre‑D

Dental Review Or Pre‑D column meaningIndicates whether pre‑service review or pre‑determination is required (Yes/N/A/. or Not covered)

Provider actionIf 'Yes', submit chart notes and narrative (and other specified documents) with pre‑determination request

Not covered valueIf entry = 'Not covered' documentation required is 'Not covered' — do not bill for reimbursement

OpenPayer

2025 ADA Code List for (non-Individual Plan) Employer Groups for Washington, Alaska

Coverage Criteria and Per‑Code Rules

ADA Procedure Codes and Coverage Status (by group)

Pre‑Determination, Documentation & Provider Guidance

Legend and Column Definitions