Procedures that require documentation
Procedure codes:
D2710-D2794
Description of service:
Crowns
Submission requirements:
- Periapical radiograph – pre-operative
- Photographs – any available
Procedure codes:
D2950-D2957
Description of service:
Core buildup, including any pins
Submission requirements:
- Periapical radiograph
- Photographs – any available
- Narrative
Procedure codes:
D2980–D2983 D5621–D5622
Description of service:
Repair requiring lab work
Submission requirements:
- Narrative
- Copy of lab bill
Procedure codes:
D3310-D3330, D3921
Description of service:
Endodontics
Submission requirements:
- Periapical radiographs – pre- and post-operative
Procedure codes:
D4210-D4212, D4240-D4245, D4260-D4285, D4341-D4342, D4381
Description of service:
Periodontics (including scaling and root planing)
Submission requirements:
- Bitewing radiographs
- Periodontal charting
- Chart notes including periodontal case type and diagnosis
Procedure codes:
D4249
Description of service:
Crown lengthening
Submission requirements:
- Bitewing radiographs – pre-treatment
- Clinical narrative
Procedure codes:
D4322 - D4323
Description of service:
Provisional splinting
Submission requirements:
- Narrative including necessity of treatment and mobility of teeth
- Periapical or bitewing radiographs documenting bone loss
Procedure codes:
D4920
Description of service:
Unscheduled dressing change
Submission requirements:
- Narrative including necessity of treatment
Procedure codes:
D6055-D6077, D6082-D6088, D6094, D6097-D6099, D6110-D6123, D6194-D6195
Description of service:
Implant supported prosthetics
Submission requirements:
- Periapical radiographs – current
- Photographs – any available
Procedure codes:
D6710-D6794
Description of service:
Prosthodontics, fixed (bridge abutment crowns)
Submission requirements:
- Periapical radiograph – pre-operative
- Photographs – any available
Procedure codes:
D7210-D7241, D7251
Description of service:
Oral surgery (impacted tooth)
Submission requirements:
- Periapical or panoramic radiographs - current
- Chart notes, detailed tooth specific
- Photographs – any available
Procedure codes:
D7530, D7540
Description of service:
Oral surgery
Submission requirements:
- Narrative including necessity of treatment
Procedure codes:
D7285–D7286
Description of service:
Oral surgery (biopsy)
Submission requirements:
- Pathology report copy
Procedure codes:
D7410–D7415, D7440–D7461, D7465
Description of service:
Oral surgery (excision of lesion)
Submission requirements:
- Pathology report copy
- Chart notes, detailed operative
Procedure codes:
D7260, D7490–D7521, D7530, D7540, D7610-D7780, D7910-D7912, D7980-D7983, D7998
Description of service:
Oral surgery (surgical incision/excision)
Submission requirements:
- Chart notes, detailed operative
Procedure codes:
D8010-D8090
Description of service:
Orthodontics
Submission requirements:
- Narrative including diagnosis, orthodontia type, and treatment length
Procedure codes:
D8210, D8680
Description of service:
Orthodontics
Submission requirements:
- Narrative including necessity of treatment
Procedure codes:
D9930, D##99
Description of service:
Miscellaneous services
Submission requirements:
- Narrative for any exceptional cases and/or unspecified codes in all categories of service (D##99)
* All pre-treatment radiographs, photographs and charting should be within 12 months of the planned treatment unless otherwise specified
Notes:
During clinical review of claims and pre-treatment estimates, Delta Dental reserves the right to request radiographic images and/or documentation for procedures that otherwise may be identified as not requiring the submission of documentation.
An itemized Explanation of Benefits is required for all procedures when Delta Dental is the secondarycarrier.
