ModifiedUnitedHealthcarePolicy DRG042.21

National Standardized Dental Claim Review Guidelines (for Commercial Only)

Guidance for adjudication of dental claims (CDT codes) under UnitedHealthcare standard Commercial Dental Plans; describes documentation requirements and related dental policies for providers submitting claims.

Policy Summary

PayerUnitedHealthcare

PolicyNational Standardized Dental Claim Review Guidelines (for Commercial Only)

Policy CodePolicy DRG042.21

Change TypeCode list and documentation revisions

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit requested documentation with coverage requests and verify member-specific benefits and applicable mandates.

SourceLink

POLICY UPDATE CHANGES

Revised list of applicable CDT codes and documentation requirements across multiple categories (Preventive, Periodontics, Removable Prosthodontics, Implants, Oral and Maxillofacial Surgery, Anesthesia).

Added D6049, D6280, D9224, D9225, D9244, D9245, D9246, and D9247 to the code list.

Removed D1352 and D9248 from the applicable CDT code list.

Updated related policy references for D7953 to point to the Bone Replacement Grafts clinical policy and removed a prior link.

Applies to Commercial plansplan applicability

~120procedure codes listed

multiplerequire radiographs

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severalrequire narrative of necessity

1documented guideline history entries

Documentation-based Coverage Criteria

inv-01: Documentation-based coverage criteria (partial)

Documentation must be submitted with requests; specific codes have explicit documentation requirements shown below (partial list).

Submit requested documentation with the coverage request; UnitedHealthcare may periodically require additional documentation for services without specific listed requirements.

Check member-specific benefit plan and applicable federal/state mandates before submission.

Cone beam CT (one of)

D0364: Narrative of necessity including planned procedure.
D0365: Narrative of necessity including planned procedure.
D0366: Narrative of necessity including planned procedure.
D0367: Narrative of necessity including planned procedure.
D0368: Narrative of necessity including planned procedure.

D2390 (resin-based composite crown) and many resin-based composite restoration codes: provide current dated pre-operative radiographs of the tooth and a narrative of necessity; when decay is not evident on radiographs or patient is too young for radiographs, provide narrative of necessity and/or treatment records.

Existing crown considerations

For direct restoration codes (e.g., D2391–D2394, D2140–D2161, D2330–D2335): if the tooth has an existing crown, submit a narrative of necessity for the filling.

inv-02: Restorative documentation and evidence requirements

Documentation criteria for restorative procedures in this segment

Radiographs: Current dated pre-operative radiographs of the tooth are required for many single-tooth indirect restorations and crowns (examples include D2542–D2544, D2642–D2644, D2710, D2720, D2740).

Narrative when radiographs nondiagnostic: Provide a narrative of necessity and/or treatment records when decay is not evident on submitted radiographs or when the patient is too young for radiographs.

Rationale for replacement: When replacing an existing crown or veneer, provide a rationale for replacement and narrative of necessity (examples: D2710, D2962).

Endodontic references

Selected pulp/endodontic codes (e.g., D3110, D3120, D3220, D3221) are listed and relate to Non‑Surgical Endodontics or Pulpotomy policies; follow related policy documentation where noted.

inv-03: Documentation and claim support criteria (excerpt)

Documentation criteria associated with listed CDT codes in this excerpt:

D2962 (labial veneer replacement): provide rationale for replacement and narrative of necessity and/or treatment records when the defect is not evident on submitted radiograph.

Endodontic retreatment codes (D3346, D3347, D3348): provide current dated pre-operative radiographs of the tooth and a narrative of necessity.

Apicoectomy/surgical endodontic procedures (D3410, D3421, D3425, D3426 and related surgical endodontic entries): provide a narrative of necessity including history of root canal therapy.

Periodontics surgical/regenerative codes (e.g., D4249, D4260, D4261, D4263–D4268): provide current dated pre-operative radiographs of the tooth/area, complete 6‑point periodontal charting, narrative of necessity, and history of non‑surgical therapies as specified.

Non‑surgical periodontal procedures for scaling/root planing and localized antimicrobial delivery (D4341, D4342, D4381): provide current dated full series or panoramic radiographs and complete 6‑point periodontal charting.

inv-04: Documentation-linked coverage criteria

Documentation-linked coverage guidance for listed D-codes in periodontics and implant/prosthetic services.

D4910 (periodontal maintenance): narrative specifying dates of previous scaling and root planing or osseous surgery is required.

D6190 (radiographic/surgical implant index): current dated pre‑operative radiographs and narrative of necessity are required.

D6049 (scaling/debridement of single implant for peri‑implantitis): requires current dated radiographs, complete 6‑point periodontal charting, and narrative of necessity.

Implant abutment and implant prosthesis codes (examples: D6051, D6055, D6056, D6057, D6110, D6114): provide current dated radiographs of the implant in place (post‑service) or projected date of implant placement (pre‑service); narrative of medical necessity where noted.

inv-05: Documentation-based coverage criteria for listed CDT codes

Coverage for the listed implant and fixed prosthodontic codes is associated with specific documentation requirements shown per code.

For implant/abutment supported removable and fixed denture codes (e.g., D6111–D6115) and single‑crown implant/abutment supported codes (e.g., D6058, D6065–D6067, D6087): provide current dated radiographs of the implant in place (post‑service) or projected date of implant placement (pre‑service).

D6081 (peri‑implant debridement for mucositis): provide current dated radiographs of the area, complete 6‑point periodontal charting, and a narrative of medical necessity.

Certain maintenance/repair and replacement procedures (examples: D6091–D6096 grouping for replacement/re‑cement/removal) require narrative of necessity for replacement/repair as specified by the related prosthetics policy.

Maintenance/Repair N/A listing

Some maintenance/repair implant codes (D6080, D6280, D6089, D6090, D6180, D6193, D6197) are listed with Documentation Requirements = N/A in this segment; clinical notes may still be required per related policy.

inv-06: Coverage stance for listed dental procedures

Listed CDT codes and associated documentation expectations for coverage consideration.

Fixed prosthodontics retainers/retainer inlays/onlays (D6600–D6634 and related codes): current dated full‑arch pre‑operative radiographs and dental charting indicating missing teeth if not visible on radiograph are required.

Oral and maxillofacial surgery codes for impacted tooth removal (D7220–D7241): provide current dated pre‑operative panoramic radiograph (see Oral/Maxillofacial Surgery section for code‑specific N/A entries).

General coverage stance

Documentation requirements across listed codes vary by code and may include: full‑arch pre‑operative radiographs, panoramic radiograph, current dated radiographs post‑service, narrative of necessity, complete 6‑point periodontal charting, or documented as 'N/A' where no additional documentation is required.

When a code in the Oral/Maxillofacial Surgery or Adjunctive General Services sections lists Documentation Requirements = N/A, no additional documentation is required for that code in this segment; however, related policies may require documentation in specific circumstances.

inv-07: Documentation and related-policy criteria

Documentation expectations and related policy linkage for specific services in this extract:

D7953 (bone replacement graft for ridge preservation): provide a current dated radiograph of the area and a narrative of necessity or chart notes indicating the type of prosthesis placed or treatment planned and the anticipated date.

Anesthesia and sedation codes (examples D9230, D9244, D9245, D9246, D9224, D9225): provide a narrative of necessity; some codes (D9244) also require the name of drug; others (D9224, D9225, D9246/D9247) require an anesthesia/sedation record including start and stop times and, where applicable, documentation of the type of advanced airway.

Certain orthodontic codes (e.g., D8010–D8040, D8070–D8091) when submitted as EHB exception requests require state‑specific documentation per EHB exception rules; follow the related Medically Necessary Orthodontic Treatment policy.

Related policy linkage: D7953 is associated with the Bone Replacement Grafts dental clinical policy as updated in the Summary of Changes.

CDT Codes and Code-specific Notes

Diagnostic Imaging (Cone Beam CT)mixed

D0364	Cone beam CT - limited field of view (<1 whole jaw) - Narrative of necessity including planned procedure required
D0365	Cone beam CT - one full dental arch - Narrative of necessity including planned procedure required
D0366	Cone beam CT - maxilla with/without cranium - Narrative of necessity including planned procedure required
D0367	Cone beam CT - both jaws with/without cranium - Narrative of necessity including planned procedure required
D0368	Cone beam CT for TMJ series - Narrative of necessity including planned procedure required

Diagnostic Imaging (Standard Radiographs)mixed

D0210	Intraoral - complete series of radiographic images
D0220	Intraoral - periapical first radiographic image
D0230	Intraoral - periapical each additional radiographic image
D0272	Bitewings - two radiographic images
D0330	Panoramic radiographic image

Restorative - Resin-based Composite Crownmixed

D2390

Resin-based composite crown, anterior - Current dated pre-operative radiographs and narrative of necessity when decay not evident or patient too young for radiographs

Core/Post Proceduresmixed

D2949	Restorative foundation for an indirect restoration - Current dated pre-operative radiographs; narrative when decay not evident
D2950	Core buildup, including any pins when required - Current dated pre-operative radiographs; narrative when decay not evident
D2952	Post and core, indirectly fabricated - Radiographs and narrative indicating completed root canal therapy; narrative when decay not evident

Restorative - Inlays/Onlaysmixed

D2510	Inlay - metallic - one surface
D2520	Inlay - metallic - two surfaces
D2530	Inlay - metallic - three or more surfaces
D2542	Onlay - metallic - two surfaces - Current dated pre-operative bitewing radiographs of tooth

Crowns - Single Restorations Onlymixed

D2740	Crown - porcelain/ceramic - Current dated pre-operative radiographs; rationale for replacement; narrative when decay not evident; tests if cracked tooth suspected
D2750	Crown - porcelain fused to high noble metal - documentation as above
D2751	Crown - porcelain fused to predominantly base metal - documentation as above
D2780	Crown - 3/4 cast high noble metal - Current dated pre-operative radiographs; rationale for replacement; narrative when decay not evident

Other Restorative Servicesmixed

D2933	Prefabricated stainless steel crown with resin window
D2934	Prefabricated esthetic coated stainless steel crown - primary tooth
D2940	Placement of interim direct restoration
D2949	Restorative foundation for an indirect restoration - see Core/Post Procedures
D2957	Each additional prefabricated post - same tooth

Endodontics (Selected)mixed

D3110	Pulp cap - direct (excluding final restoration)
D3220	Therapeutic pulpotomy
D3310	Endodontic therapy, anterior (excluding final restoration)
D3330	Endodontic therapy, molar (excluding final restoration)
D3346	Retreatment of previous root canal therapy - anterior - Current dated pre-operative radiographs and narrative of necessity
D3351	Apexification/recalcification - initial visit

Periodontics (Selected)mixed

D4249	Clinical crown lengthening - hard tissue - Current dated radiographs; complete 6-point periodontal charting; narrative of necessity
D4260	Osseous surgery - four or more contiguous teeth per quadrant - radiographs; charting; narrative; history of non-surgical therapies
D4341	Periodontal scaling and root planing - four or more teeth per quadrant - Current dated full series or panoramic radiographs; complete 6-point charting
D4910	Periodontal maintenance - Narrative specifying dates of previous scaling and root planing or osseous surgery

Removable Prosthodontics (Selected)mixed

D5110	Complete denture - maxillary
D5120	Complete denture - mandibular
D5211	Maxillary partial denture - resin base - documentation of all missing teeth and teeth planned for extraction
D5710	Rebase complete maxillary denture - narrative indicating date of denture placement
D5840	(Not listed in source)

Implants (Selected)mixed

D6010	Surgical placement of implant body: endosteal implant - Current dated pre-operative full series or panoramic radiographs
D6051	Placement of interim implant abutment - Current dated radiographs post-service or projected date pre-service; narrative of medical necessity
D6049	Scaling and debridement of a single implant for peri-implantitis - Current dated radiographs; complete 6-point periodontal charting; narrative of necessity
D6065	Implant supported porcelain/ceramic crown - Current dated radiographs post-service or projected pre-service

Implant Supported Prosthetics - Single Crowns (Abutment & Implant Supported)mixedCovered

D6061	Abutment supported porcelain fused to metal crown (noble) - Current dated radiographs post-service or projected date pre-service
D6062	Abutment supported cast metal crown (high noble) - documentation as above
D6065	Implant supported porcelain/ceramic crown - documentation as above
D6094	Abutment supported crown - titanium and titanium alloys - documentation as above
D6097	Abutment supported crown - porcelain fused to titanium - documentation as above

Fixed Partial Denture Retainers and Pontics (Selected)mixedCovered

D6205	Pontic - indirect resin based composite - Current dated full arch pre-operative radiographs; dental charting indicating missing teeth
D6210	Pontic - cast high noble metal - documentation as above
D6253	Interim pontic - further treatment required prior to final impression - Current dated full arch pre-operative radiographs; narrative stating further treatment

Oral and Maxillofacial Surgery - Extractions (Selected)mixedCovered

D7111	Extraction, coronal remnants - deciduous tooth
D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
D7210	Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth
D7220	Removal of impacted tooth - soft tissue - Current dated pre-operative panoramic radiograph; narrative of necessity
D7230	Removal of impacted tooth - partially bony - Current dated pre-operative panoramic radiograph; narrative of necessity
D7240	Removal of impacted tooth - completely bony - Current dated pre-operative panoramic radiograph
D7241	Removal of impacted tooth - completely bony with unusual surgical complications - Current dated pre-operative panoramic radiograph

Oral and Maxillofacial Surgery - OthermixedCovered

D7250	Removal of residual roots (cutting procedure) - (codes D7250-D7288 series referenced)
D7291	Removal of partially erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or sectioning of tooth
D7310	Alveoloplasty in conjunction with extractions - per quadrant (codes D7310-D7360 series referenced)
D7410	Excision of benign odontogenic cyst or non-neoplastic lesion - simple
D7461	Removal of torus palatinus
D7472	Removal of torus mandibularis - bilateral
D7473	Removal of torus mandibularis - unilateral
D7509	(Refer to series D7509-D7560 for fascial space drainage and related procedures)
D7510	Incision and drainage of abscess - intraoral soft tissue
D7530	Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue

1–10 of 13

1/2

Oral Surgery Miscellaneous (Codes Window)mixed

D7511	(listed in source)
D7520	Incision and drainage of abscess - extraoral soft tissue
D7521	Incision and drainage of abscess - extraoral soft tissue - complicated
D7530	Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue
D7540	Removal of reaction producing foreign bodies, musculoskeletal system

Adjunctive General Services (Selected)mixed

D9110	Palliative (emergency) treatment of dental pain - minor procedure
D9210	Local anesthesia not in conjunction with operative or surgical procedures
D9230	Administration of nitrous oxide - Narrative of necessity
D9944	Occlusal guard - hard appliance, full arch - Current dated full mouth radiographs; narrative of necessity

Comprehensive CDT window (misc codes referenced) mixed

D7250-D7288	Series: removal of residual roots and related procedures (refer to full code list for specifics)
D7310-D7360	Series: alveoloplasty and related procedures (refer to full code list for specifics)
D7509-D7560	Series: fascial space drainage and related oral surgery procedures (refer to full code list for specifics)
D7530-D7560	Overlapping referenced codes in oral surgery window (see above individual codes)

Periodontics Required Documentation Highlightsmixed

D4263	Bone replacement graft - retained natural tooth - first site in quadrant - Current dated pre-operative radiographs; complete 6-point periodontal charting
D6102	Debridement of osseous contouring of a peri-implant defect - radiographs; charting; narrative of necessity

Implant Documentation Requirementsmixed

D6051	Current dated radiographs of implant in place (post-service) or projected date of implant placement (pre-service) and narrative of medical necessity
D6065	Current dated radiographs of implant in place (post-service) or projected date of implant placement (pre-service)

Cone Beam CT Documentationmixed

D0364-D0368

Narrative of necessity including planned procedure required for codes D0364-D0368

Provider Submission and Documentation Actions

Documentation Required

Provider Submission Checklist

Submit requested documentation with coverage request. Check member-specific benefit plan and applicable federal or state mandates. UnitedHealthcare may periodically request documentation for services that do not have explicit requirements listed. Provide complete, legible records to support medical necessity.

Always include current dated radiographs when specified.
When narrative of necessity is requested, include history, clinical findings, and planned treatment.
Provide dental charting when radiographs do not show missing teeth.

Documentation Required

Single Tooth Direct Restorations (examples)

Single-tooth direct restorations (resin-based composites) may require additional documentation when an existing crown is present or when a defect is not evident on radiograph. For resin-based composite crowns provide current dated pre-operative radiographs of the tooth.

Affected example codes: D2330, D2331, D2332, D2335, D2390.

Key Terms and Explanations

inv-57: Dental Claim Review Guideline

Document purposeDental Claim Review Guideline: provides adjudication guidance for UnitedHealthcare standard Commercial Dental Plans and links to related Dental Clinical Policies.

Provider actionBefore using the guideline, check member-specific benefit plan documents and applicable federal/state mandates.

Source for CDTRefer to the most current version of the CDT (ADA) for code descriptions.

inv-58: Current Dental Terminology (CDT)

DefinitionCurrent Dental Terminology (CDT): refer to the American Dental Association's most current CDT code set for official code descriptions and guidance.

UsageCDT codes in this guideline correspond to ADA definitions; providers should reference CDT for coding accuracy.

Guideline History and Changes

Policy Summary

PayerUnitedHealthcare

PolicyNational Standardized Dental Claim Review Guidelines (for Commercial Only)

Policy CodePolicy DRG042.21

Change TypeCode list and documentation revisions

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit requested documentation with coverage requests and verify member-specific benefits and applicable mandates.

SourceLink

On This Page

Periodontal maintenance (D4910): provide a narrative specifying dates of previous scaling and root planing or osseous surgery.

Removable prosthodontics codes listed in this excerpt (e.g., D5110–D5140, D5211): documentation requirements are shown as N/A in this excerpt; refer to the Removable Prosthodontics related policy for full requirements.

Fixed prosthodontics pontics and retainers (e.g., D6205, D6210, D6211, D6240, D6253; D6600–D6609 series): provide current dated full‑arch pre‑operative radiographs and dental charting indicating missing teeth if not visible on radiograph; D6253 additionally requires a narrative that further treatment or diagnosis is necessary prior to final impression.

Guideline revisions effective 01/01/2026 added several implant and anesthesia codes and revised documentation requirements for multiple entries; consult the Guideline History for details when applying documentation expectations.

If tooth has an existing crown: include a narrative of necessity explaining rationale for filling or restoration.

For D2390 (resin-based composite crown, anterior): include current dated pre-operative radiographs.

Documentation Required

Crowns - Single Restorations Only (examples)

Single crown procedures require current dated pre-operative radiographs and clear justification when replacing existing crowns. When decay is not evident on radiographs or when diagnosing cracked tooth syndrome, include a narrative of necessity, treatment records, and specific diagnostic tests performed.

Affected example codes: D2710, D2712, D2720, D2721.
Provide rationale for replacement of existing crowns, if applicable.
Include narrative of necessity and treatment records when radiographs do not show decay; for cracked tooth syndrome, document specific diagnostic tests and findings.

Documentation Required

Endodontics / Pulp procedures

Selected endodontic and pulp procedures may list documentation as N/A, but many endodontic services require current dated pre-operative radiographs and a narrative of necessity. Retreatment and surgical endodontic procedures generally require radiographs and documentation of prior endodontic history.

Examples: D3110, D3120, D3220, D3221 (pulp procedures) — Documentation: N/A in some entries but follow Non-Surgical Endodontics policy when applicable.
Retreatment codes D3346–D3348: include current dated pre-operative radiographs and narrative of necessity.
Apicoectomy and related surgical endodontics (D3410, D3421, D3425, D3426): provide a narrative of necessity including history of prior root canal therapy.

Documentation Required

Periodontics documentation actions

For many periodontal surgical and regenerative procedures, provide current dated pre-operative radiographs, complete 6-point periodontal charting, a narrative of necessity, and history of non-surgical therapies where indicated. Periodontal maintenance requires documentation of prior periodontal therapy dates.

Examples and key requirements: D4249 (clinical crown lengthening — hard tissue): current dated pre-op radiographs; complete 6-point charting; narrative of necessity.
D4260/D4261 (osseous surgery): current dated pre-op radiographs; complete 6-point charting; narrative of necessity; history of non-surgical therapies.
D4263–D4265 (bone replacement grafts/biologic materials): current dated pre-op radiographs and complete periodontal charting; for biologics include name of material and application.
D4341 (scaling and root planing): current dated full series or panoramic radiographs and complete 6-point periodontal charting.
D4910 (periodontal maintenance): provide narrative specifying dates of previous scaling/root planing or osseous surgery.

Documentation Required

Pre-Surgical implant index requirements

Pre-surgical implant indexing requires current dated pre-operative radiographs. Include narrative of necessity when requested by implant placement and peri-implant treatment policies.

D6190 (radiographic/surgical implant index): current dated pre-operative radiographs.
Confirm member benefit coverage and submit index radiographs with pre-service requests when applicable.

Documentation Required

Documentation prerequisites for implant codes

Most implant surgical and prosthetic codes require current dated radiographs showing either the implant in place (post-service) or the projected date of implant placement (pre-service). Provide complete periodontal charting and narrative of necessity for peri-implant procedures.

Surgical placement codes (D6010, D6012, D6013, D6040, D6050): current dated pre-operative full series or panoramic radiographs.
D6051, D6055, D6056, D6057, D6191/D6192 and implant prosthetic codes: current dated radiographs of implant in place (post-service) or projected implant placement date (pre-service).
For D6102 (debridement/osseous contouring of peri-implant defect): current dated radiographs, complete 6-point periodontal charting, and narrative of necessity.

Documentation Required

Peri-implant procedure documentation

Peri-implant procedures require documentation demonstrating peri-implant disease and clinical findings. Provide complete periodontal charting and a narrative of necessity describing clinical signs and prior treatments.

D6049 (scaling/debridement of single implant for peri-implantitis): current dated radiographs of area; complete 6-point periodontal charting; narrative of necessity documenting inflammation, bleeding on probing, and increased pocket depths.
D6081 (peri-implant debridement): complete 6-point periodontal charting and narrative of necessity.

Documentation Required

Maintenance/repair codes documentation notes

Some implant maintenance and repair codes list Documentation Requirements = N/A, but many still require narrative of necessity when performed for clinical reasons. When parts are replaced or prostheses are repaired, include justification and clinical findings.

Codes often N/A: D6089 (accessing/retorquing loose implant screw), D6090 (repair of implant/abutment supported prosthesis), D6180 (implant maintenance procedures) — but include documentation when clinically indicated.
Codes requiring narrative: D6091 (replacement of part of precision attachment), D6092–D6093 (re-cement or re-bond implant-supported restorations), D6096 (remove broken implant retaining screw), D6193 (replacement of an implant part) — include narrative of necessity.

Documentation Required

Documentation requirement — Fixed Prosthodontics

Fixed prosthodontic procedures require current dated full arch pre-operative radiographs and dental charting indicating missing teeth when not evident on radiographs. Provide narratives stating what further treatment or diagnosis is medically necessary when requested.

Examples: D6600–D6605 (retainer inlays) and D6780 (retainer crown) — current dated full arch pre-operative radiographs and dental charting for missing teeth.
D6549, D6753, D6793: include dental charting and, for D6793, a narrative describing further necessary treatment or diagnosis.
D6930 (re-cement fixed partial denture): Documentation = N/A; D6980 (fixed partial denture repair due to material failure): include narrative of necessity.

Documentation Required

Documentation requirement — Impacted tooth extractions

Impacted tooth extraction codes require current dated pre-operative panoramic radiographs and a narrative of necessity when specified.

D7220 (surgical removal of erupted tooth): include narrative of necessity when requested.
D7230 (removal of impacted tooth — partially bony), D7240 (completely bony), D7241 (completely bony with unusual complications): current dated pre-operative panoramic radiograph and narrative of necessity.

Documentation Required

Orthodontics EHB exception documentation

Orthodontic codes that are subject to Essential Health Benefits (EHB) exception rules require state-specific documentation for exception requests. Follow the applicable state requirements when submitting EHB exception documentation for limited or comprehensive orthodontic treatment.

EHB exception documentation applies to codes such as D8010–D8040 (limited orthodontic treatment) and D8070–D8080 (comprehensive orthodontic treatment) when noted.
Include all state-required materials and forms for EHB exception requests as applicable.

inv-59: Narrative of necessity

DefinitionNarrative of necessity: a written statement describing the clinical rationale for a requested service; required for many CDT codes when specified.

When requiredRequested when decay is not evident on radiographs, for certain anesthesia services, implant procedures, and other listed codes.

PurposeSupports medical necessity determinations and adjudication of claims.

inv-60: Cracked tooth syndrome documentation

RequirementCracked tooth syndrome diagnoses require supportive documentation and specific diagnostic tests when provided without clear radiographic decay.

Associated codesApplies to single-tooth indirect restoration codes where cracked tooth syndrome is listed as a potential diagnosis.

ActionInclude diagnostic test results and narrative of necessity when applicable.

inv-61: Complete 6-point periodontal charting

DefinitionComplete 6-point periodontal charting: full periodontal probing around each tooth/site; required documentation element for many surgical periodontics and peri-implant procedures.

When requiredRequired with current dated radiographs and narrative of necessity for codes such as D4249, D4260, D4261, D4263–D4267, D6081, D6102.

inv-62: Narrative of necessity

DefinitionNarrative of necessity: see prior entry — written rationale supporting the clinical need for the service.

ExamplesUsed for restorative replacements, implants, peri-implant procedures, and select anesthesia services.

inv-63: Current dated pre-operative radiograph

DefinitionCurrent dated pre‑operative radiograph: radiographic image taken near the time of proposed service (e.g., bitewing, periapical, panoramic) required for many indirect restorations and crowns.

ExamplesBitewing/periapical for onlays/inlays (D2542–D2544, D2642); full series/panoramic for implant pre-surgical planning (D6010, D6190).

inv-64: D4910 documentation requirement

RequirementD4910 (periodontal maintenance) requires a narrative specifying dates of previous scaling and root planing or osseous surgery.

PurposeEnsures maintenance is medically indicated based on prior periodontal therapy.

inv-65: implant radiograph and narrative requirement

RequirementMany implant and pre-surgical implant procedures require current dated pre‑operative full series or panoramic radiographs and a narrative of necessity.

ExamplesD6190, D6010, D6012, D6013, D6040, D6050 list pre‑op radiograph and narrative requirements.

inv-66: denture rebase/reline documentation

RequirementDenture rebase and reline procedures require a narrative indicating the date of original denture placement.

Codes (examples)D5710–D5725, D5730–D5751, D5760–D5761

inv-67: D6081 — Scaling and debridement of single implant

RequirementD6081 (scaling and debridement of a single implant for mucositis) requires current dated radiographs, complete 6‑point periodontal charting, and a narrative of necessity.

Clinical detailD6081 is specific to mucositis with inflammation, bleeding on probing and increased pocket depths; includes cleaning implant surfaces without flap entry.

inv-68: D6080 / D6280 — maintenance procedures documentation notes

NotesSome implant maintenance procedures (e.g., D6080, D6280) and repairs list Documentation Requirements = N/A in this segment, though related policy may require clinical notes for adjudication.

ExamplesD6080, D6280, D6089, D6090, D6180

inv-69: Documentation Requirements

RequirementFor many Fixed Prosthodontics codes provide current dated full‑arch pre‑operative radiographs and dental charting indicating missing teeth if not visible on radiograph.

Codes (examples)D6600–D6634, D6710–D6794

PurposeSupports prosthetic design and verification of edentulous spaces prior to fabrication.

inv-70: Guideline History/Revision Information

SectionGuideline History/Revision Information: Summary of Changes dated 01/01/2026.

Material changesAdded D6049 and D6280 among implant updates; added several anesthesia codes (D9224–D9225, D9244–D9247); removed D9248 and D1352.

Related policy updateUpdated related policy references for D7953 to Bone Replacement Grafts - Dental Clinical Policy.