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Attachment J-10 Military Dental Service Points of Contacts (DSPOCs) Material Checklist
Attachment J-9 Military Dental Service Points of Contacts (DSPOCs) Material Checklist
1.0. The purpose of the Active Duty Dental Program (ADDP) is to ensure military members are world-wide deployable. It is not a dental insurance plan to provide for all dental care that could be provided.
2.0. The following is a list of materials needed for the Military Dental Service Points of Contacts (DSPOCs) to review cases submitted under the ADDP for Service Members living in remote areas. Please note that these materials are only requested when the case must be reviewed by a DSPOC per ADDP contractual guidelines. Additionally, there are specific materials requested when the DSPOCs are reviewing appeals.
2.1. Routine care (R), that does not exceed $750 in charges per procedure or appointment or $1,500 for a complete treatment plan, does not need to be pre-authorized
2.2. The documentation materials indicated below by Current Dental Terminology (CDT) code are considered a minimum requirement for review and pre-authorization by the DSPOCs. Under certain circumstances the DSPOCs may request additional documentation material to clarify the requested treatment or prior treatment before rendering a decision for pre-authorization. All documentation material submitted for review must be of a diagnostic quality. Periodontal charting and narratives must be legible and the print dark enough to be read. Less than 6 point periodontal charting is not acceptable. Original or duplicate radiographic images must be of an overall acceptable diagnostic quality, density and contrast. Periapical radiographs must show the entire apex or apices, the periradicular area, and the clinical crown of the subject tooth/teeth being reviewed.
2.3. Narrative Requirements: The goal is for the approved treatment plan to meet the needs of all involved. When a narrative is indicated or requested, the provider should provide all pertinent clinical information that is not apparent on the other documentation provided, i.e. radiographs and/or photographs. The total package should paint a complete picture that allows the military dentist reviewers to mesh the proposed dental treatment with Service guidelines and military readiness requirements. If the information submitted is not adequate to make a determination of the appropriateness of the dental service, the DSPOC reserves the right to request additional information prior to final authorization or denial for payment of a procedure.
Code Description
E Emergency Care – No authorization required
R Routine Care - No authorization required (unless over $750)
S Specialty Care – Authorization is required
N Non-covered procedure
CDT Code
| Description |
| Materials Needed for Preauthorization Review |
| Additional Materials Needed for Appeals Review |
| D0120 |
| R |
| Periodic oral evaluation – established patient |
| N/A |
| Narrative/Reason for Appeal |
| D0140 |
| R |
| Limited oral evaluation - problem focused |
| N/A |
| Narrative/Reason for Appeal |
| D0150 |
| R |
| Comprehensive oral evaluation –new or established patient |
| N/A |
| Narrative/Reason for Appeal |
| D0160 |
| R |
| Detailed and extensive oral evaluation - problem focused, by report |
| N/A |
| Narrative/Reason for Appeal |
| D0170 |
| R |
| Re-evaluation-limited, problem focused (not post-operative visit, established patient) |
| N/A |
| Narrative/Reason for Appeal |
| D0171 |
| N |
| Re-evaluation – post-operative office visit |
| N/A |
| Narrative/Reason for Appeal |
| D0180 |
| R |
| Comprehensive periodontal evaluation – new or established patient |
| N/A |
| Narrative/Reason for Appeal |
| D0190 |
| N |
| Screening of a patient |
| N/A |
| Narrative/Reason for Appeal |
| D0191 |
| N |
| Assessment of a patient |
| N/A |
| Narrative/Reason for Appeal |
| D0210 |
| R |
| Intraoral - complete series of radiographic images |
| N/A |
| Narrative/Reason for Appeal |
| D0220 |
| R |
| Intraoral - periapical first radiographic image |
| N/A |
| Narrative/Reason for Appeal |
| D0230 |
| R |
| Intraoral - periapical each additional radiographic image |
| N/A |
| Narrative/Reason for Appeal |
| D0240 |
| R |
| Intraoral - occlusal radiographic image |
| N/A |
| Narrative/Reason for Appeal |
| D0250 |
| R |
| Extraoral - 2D projection radiographic image created using a stationary radiation source, and detector |
| N/A |
| Narrative/Reason for Appeal |
| D0251 |
| R |
| Extraoral posterior dental radiographic image |
| N/A |
| Narrative/Reason for Appeal |
| D0270 |
| R |
| Bitewing - single radiographic image |
| N/A |
| Narrative/Reason for Appeal |
| D0272 |
| R |
| Bitewings - two radiographic images |
| N/A |
| Narrative/Reason for Appeal |
| D0273 |
| R |
| Bitewings – three radiographic images |
| N/A |
| Narrative/Reason for Appeal |
| D0274 |
| R |
| Bitewings - four radiographic images |
| N/A |
| Narrative/Reason for Appeal |
| D0277 |
| R |
| Vertical bitewings - 7 to 8 radiographic images |
| N/A |
| Narrative/Reason for Appeal |
| D0310 |
| N |
| Sialography |
| N/A |
| Narrative/Reason for Appeal |
| D0320 |
| S |
| Temporomandibular joint arthrogram, including injection |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0321 |
| S |
| Other temporomandibular joint radiographic images, by report |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0322 |
| S |
| Tomographic survey |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0330 |
| R |
| Panoramic radiographic image |
| N/A |
| Narrative/Reason for Appeal |
| D0340 |
| S |
| 2D cephalometric radiographic image – acquisition, measurement and analysis |
| Narrative |
| Narrative/Reason for Appeal |
| D0350 |
| S |
| 2D oral/facial photographic images obtained intraorally or extraorally |
| Narrative |
| Narrative/Reason for Appeal |
| D0351 |
| S |
| 3D photographic image |
| Narrative |
| Narrative/Reason for Appeal |
| D0364 |
| S |
| Cone beam Computed Tomography (CT) capture and interpretation with limited field of view – less than one whole jaw |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0365 |
| S |
| Cone beam CT capture and interpretation with field of view of one full dental arch – mandible |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0366 |
| S |
| Cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0367 |
| S |
| Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0368 |
| S |
| Cone beam CT capture and interpretation for TMJ series including two or more exposures |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0369 |
| S |
| Maxillofacial Magnetic Resonance Imaging (MRI) capture and interpretation |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0370 |
| S |
| Maxillofacial ultrasound capture and interpretation |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0371 |
| S |
| Sialoendoscopy capture and interpretation |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0380 |
| S |
| Cone beam CT image capture with limited field of view – less than one whole jaw |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0381 |
| S |
| Cone beam CT image capture with field of view of one full dental arch – mandible |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0382 |
| S |
| Cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0383 |
| S |
| Cone beam CT image capture with field of view of both jaws, with or without cranium |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0384 |
| S |
| Cone beam CT image capture for TMJ series including two or more exposures |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0385 |
| S |
| Maxillofacial MRI image capture |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0386 |
| S |
| Maxillofacial ultrasound image capture |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0391 |
| S |
| Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0393 |
| S |
| Treatment simulation using 3D image volume |
| Narrative |
| Narrative/Reason for Appeal |
| D0394 |
| S |
| Digital subtraction of two or more images or image volumes of the same modality |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0395 |
| S |
| Fusion of two or more 3D image volumes of one or more modalities |
| Narrative & Pano |
| Narrative/Reason for Appeal & Pano |
| D0411 |
| S |
| HbA1c in-office point of service testing |
| Narrative |
| Narrative/Reason for Appeal |
| D0412 |
| S |
| Blood glucose level test – in office using a glucose meter |
| Narrative |
| Narrative/Reason for Appeal |
| D0414 |
| S |
| Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report |
| Narrative |
| Narrative/Reason for Appeal |
| D0415 |
| S |
| Collection of microorganisms for culture and sensitivity |
| Narrative |
| Narrative/Reason for Appeal |
| D0416 |
| S |
| Viral culture |
| Narrative |
| Narrative/Reason for Appeal |
| D0417 |
| S |
| Collection and preparation of saliva sample for laboratory diagnostic testing |
| Narrative |
| Narrative/Reason for Appeal |
| D0418 |
| S |
| Analysis of saliva sample |
| Narrative |
| Narrative/Reason for Appeal |
| D0419 |
| S |
| Assessment of salivary flow by measurement |
| Narrative |
| Narrative/Reason for Appeal |
| D0422 |
| N |
| Collection and preparation of genetic sample material for laboratory analysis and report |
| Narrative |
| Narrative/Reason for Appeal |
| D0423 |
| N |
| Genetic test for susceptibility to diseases – specimen analysis |
| Narrative |
| Narrative/Reason for Appeal |
| D0425 |
| S |
| Caries susceptibility test |
| Narrative |
| Narrative/Reason for Appeal |
| D0431 |
| N |
| Adjunctive pre-diagnostic test that aids in the detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures |
| N/A |
| Narrative/Reason for Appeal |
| D0460 |
| S |
| Pulp vitality tests |
| Narrative |
| Narrative/Reason for Appeal |
| D0470 |
| N |
| Diagnostic casts |
| N/A |
| Narrative/Reason for Appeal |
| D0472 |
| S |
| Accession of tissue, gross examination, preparation and transmission of written report |
| Narrative |
| Narrative/Reason for Appeal |
| D0473 |
| S |
| Accession of tissue, gross and microscopic examination, preparation and transmission of written report |
| Narrative |
| Narrative/Reason for Appeal |
| D0474 |
| S |
| Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report |
| Narrative |
| Narrative/Reason for Appeal |
| D0475 |
| S |
| Decalcification procedure |
| Narrative |
| Narrative/Reason for Appeal |
| D0476 |
| S |
| Special stains for microorganisms |
| Narrative |
| Narrative/Reason for Appeal |
| D0477 |
| S |
| Special stains, not for microorganisms |
| Narrative |
| Narrative/Reason for Appeal |
| D0478 |
| S |
| Immunohistochemical stains |
| Narrative |
| Narrative/Reason for Appeal |
| D0479 |
| S |
| Tissue in-situ hybridization, including interpretation |
| Narrative |
| Narrative/Reason for Appeal |
| D0480 |
| S |
| Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report |
| Narrative |
| Narrative/Reason for Appeal |
| D0481 |
| S |
| Electron microscopy |
| Narrative |
| Narrative/Reason for Appeal |
| D0482 |
| S |
| Direct immunofluorescence |
| Narrative |
| Narrative/Reason for Appeal |
| D0483 |
| S |
| Indirect immunofluorescence |
| Narrative |
| Narrative/Reason for Appeal |
| D0484 |
| S |
| Consultation on slides prepared elsewhere |
| Narrative |
| Narrative/Reason for Appeal |
| D0485 |
| S |
| Consultation, including preparation of slides from biopsy material supplied by referring source |
| Narrative |
| Narrative/Reason for Appeal |
| D0486 |
| S |
| Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report |
| Narrative |
| Narrative/Reason for Appeal |
| D0502 |
| S |
| Other oral pathology procedures, by report |
| Narrative |
| Narrative/Reason for Appeal |
| D0600 |
| N |
| Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin and cementum |
| N/A |
| Narrative/Reason for Appeal |
| D0601 |
| N |
| Caries risk assessment and documentation, with a finding of low risk |
| N/A |
| Narrative/Reason for Appeal |
| D0602 |
| N |
| Caries risk assessment and documentation, with finding of moderate risk |
| N/A |
| Narrative/Reason for Appeal |
| D0603 |
| N |
| Caries risk assessment of documentation, with finding of high risk |
| N/A |
| Narrative/Reason for Appeal |
| D0999 |
| N |
| Unspecified diagnostic procedure, by report |
| N/A |
| Narrative/Reason for Appeal |
| D1110 |
| R |
| Prophylaxis – adult |
| N/A |
| Narrative/Reason for Appeal |
| D1206 |
| R |
| Topical application of fluoride varnish |
| N/A |
| Narrative/Reason for Appeal |
| D1208 |
| R |
| Topical application of fluoride – excluding varnish |
| N/A |
| Narrative/Reason for Appeal |
| D1310 |
| N |
| Nutritional counseling for control of dental disease |
| N/A |
| Narrative/Reason for Appeal |
| D1320 |
| N |
| Tobacco counseling for the control and prevention of oral disease |
| N/A |
| Narrative/Reason for Appeal |
| D1330 |
| N |
| Oral hygiene instructions |
| N/A |
| Narrative/Reason for Appeal |
| D1351 |
| S |
| Sealant - per tooth |
| Patients Age; Bite Wing X-ray (BWX); Caries Risk Assessment |
| Narrative/Reason for Appeal & Patients Age; BWX; Caries Risk Assessment |
| D1352 |
| S |
| Preventive resin restoration in a moderate to high caries risk patient – permanent tooth |
| Patients Age; Bite Wing X-ray (BWX); Caries Risk Assessment |
| Narrative/Reason for Appeal & Patients Age; BWX; Caries Risk Assessment |
| D1353 |
| S |
| Sealant repair – per tooth |
| Narrative |
| Narrative/Reason for Appeal |
| D1354 |
| N |
| Interim caries arresting medicament application – per tooth |
| Narrative |
| Narrative/Reason for Appeal |
| D1510 |
| N |
| Space maintainer – fixed – unilateral – per quadrant |
| N/A |
| Narrative/Reason for Appeal |
| D1516 |
| N |
| Space maintainer – fixed – bilateral, maxillary |
| N/A |
| Narrative/Reason for Appeal |
| D1517 |
| N |
| Space maintainer – fixed – bilateral, mandibular |
| D1520 |
| N |
| Space maintainer – removable – unilateral – per quadrant |
| N/A |
| Narrative/Reason for Appeal |
| D1526 |
| N |
| Space maintainer – removable – bilateral, maxillary |
| N/A |
| Narrative/Reason for Appeal |
| D1527 |
| N |
| Space maintainer – removable – bilateral, mandibular |
| N/A |
| Narrative/Reason for Appeal |
| D1551 |
| N |
| Re-cement or rebond bilateral space maintainer - maxillary |
| N/A |
| Narrative/Reason for Appeal |
| D1552 |
| N |
| Re-cement or rebond bilateral space maintainer - mandibular |
| N/A |
| Narrative/Reason for Appeal |
| D1553 |
| N |
| Re-cement or rebond bilateral space maintainer – per quadrant |
| N/A |
| Narrative/Reason for Appeal |
| D1556 |
| S |
| Removal of fixed unilateral space maintainer – per quadrant |
| Patient’s Age; BWX |
| Narrative/Reason for Appeal; Patient’s Age; BWX |
| D1557 |
| S |
| Removal of fixed bilateral space maintainer – maxillary |
| Patient’s Age; BWX |
| Narrative/Reason for Appeal; Patient’s Age; BWX |
| D1558 |
| S |
| Removal of fixed bilateral space maintainer – mandibular |
| Patient’s Age; BWX |
| Narrative/Reason for Appeal; Patient’s Age; BWX |
| D1575 |
| N |
| Distal shoe space maintainer-fixed-unilateral – per quadrant |
| N/A |
| Narrative/Reason for Appeal |
| D1999 |
| N |
| Unspecified preventive procedure, by report |
| N/A |
| Narrative/Reason for Appeal |
| D2140 |
| R |
| Amalgam one surface, permanent or primary |
| BWX |
| Narrative/Reason for Appeal & BWX |
| D2150 |
| R |
| Amalgam two surfaces, permanent or primary |
| BWX |
| Narrative/Reason for Appeal & BWX |
| D2160 |
| R |
| Amalgam three surfaces, permanent or primary |
| BWX |
| Narrative/Reason for Appeal & BWX |
| D2161 |
| R |
| Amalgam four or more surfaces, permanent or primary |
| BWX |
| Narrative/Reason for Appeal & BWX |
| D2330 |
| R |
| Resin based composite one surface, anterior |
| Periapical X-ray (PA) |
| Narrative/Reason for Appeal & PA |
| D2331 |
| R |
| Resin based composite two surfaces, anterior |
| PA |
| Narrative/Reason for Appeal & PA |
| D2332 |
| R |
| Resin based composite three surfaces, anterior |
| PA |
| Narrative/Reason for Appeal & PA |
| D2335 |
| R |
| Resin based composite four or more surfaces or involving incisal angle (anterior) |
| PA |
| Narrative/Reason for Appeal & PA |
| D2390 |
| S |
| Resin based composite crown, anterior |
| PA |
| Narrative/Reason for Appeal & PA |
| D2391 |
| R |
| Resin based composite one surface, posterior |
| BWX |
| Narrative/Reason for Appeal & BWX |
| D2392 |
| R |
| Resin based composite two surfaces, posterior |
| BWX |
| Narrative/Reason for Appeal & BWX |
| D2393 |
| R |
| Resin based composite three surfaces, posterior |
| BWX |
| Narrative/Reason for Appeal & BWX |
| D2394 |
| R |
| Resin based composite – four or more surfaces, posterior |
| BWX |
| Narrative/Reason for Appeal & BWX |
| D2410 |
| N |
| Gold foil – one surface |
| N/A |
| Narrative/Reason for Appeal |
| D2420 |
| N |
| Gold foil – two surfaces |
| N/A |
| Narrative/Reason for Appeal |
| D2430 |
| N |
| Gold foil – three surfaces |
| N/A |
| Narrative/Reason for Appeal |
| D2510 |
| N |
| Inlay – metallic - one surface |
| BWX and PA per unit |
| Narrative/Reason for Appeal & BWX; PA per unit |
| D2520 |
| N |
| Inlay – metallic - two surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & BWX; PA per unit |
| D2530 |
| N |
| Inlay – metallic - three or more surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & BWX; PA per unit |
| D2542 |
| S |
| Onlay - metallic - two surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2543 |
| S |
| Onlay - metallic - three surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2544 |
| S |
| Onlay - metallic - four or more surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2610 |
| S |
| Inlay porcelain/ceramic one surface |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2620 |
| S |
| Inlay porcelain/ceramic two surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2630 |
| S |
| Inlay porcelain/ceramic three or more surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2642 |
| S |
| Onlay porcelain/ceramic two surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2643 |
| S |
| Onlay porcelain/ceramic three surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2644 |
| S |
| Onlay porcelain/ceramic four or more surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2650 |
| N |
| Inlay resin based composite one surface |
| BWX and PA per unit |
| Narrative/Reason for Appeal & BWX; PA per unit |
| D2651 |
| N |
| Inlay resin based composite two surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & BWX; PA per unit |
| D2652 |
| N |
| Inlay resin based composite three or more surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & BWX; PA per unit |
| D2662 |
| N |
| Onlay resin based composite two surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & BWX; PA per unit |
| D2663 |
| N |
| Onlay resin based composite three surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & BWX; PA per unit |
| D2664 |
| N |
| Onlay resin based composite four or more surfaces |
| BWX and PA per unit |
| Narrative/Reason for Appeal & BWX; PA per unit |
| D2710 |
| N |
| Crown – resin-based composite (indirect) |
| N/A |
| Narrative/Reason for Appeal |
| D2712 |
| N |
| Crown –3/4 resin-based composite (indirect) |
| N/A |
| Narrative/Reason for Appeal |
| D2720 |
| N |
| Crown - resin with high noble metal |
| N/A |
| Narrative/Reason for Appeal |
| D2721 |
| N |
| Crown - resin with predominantly base metal |
| N/A |
| Narrative/Reason for Appeal |
| D2722 |
| N |
| Crown - resin with noble metal |
| N/A |
| Narrative/Reason for Appeal |
| D2740 |
| S |
| Crown - porcelain/ceramic |
| BWX and PA per unit. Verify that crowns are either Lithium Disilicate (IPS E.Max CAD or Ivoclar Vivadent) or Full Contour Zirconia (i.e., Bruxir, Lava Plus, Zirlux) |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2750 |
| S |
| Crown - porcelain fused to high noble metal |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2751 |
| N |
| Crown - porcelain fused to predominantly base metal |
| N/A |
| Narrative/Reason for Appeal |
| D2752 |
| S |
| Crown - porcelain fused to noble metal |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2753 |
| S |
| Crown – porcelain fused to titanium and titanium alloys |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX and PA per unit |
| D2780 |
| S |
| Crown – 3/4 cast high noble metal |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2781 |
| N |
| Crown - 3/4 cast predominantly base metal |
| N/A |
| Narrative/Reason for Appeal |
| D2782 |
| S |
| Crown – 3/4 cast noble metal |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2783 |
| N |
| Crown – 3/4 porcelain/ceramic |
| N/A |
| Narrative/Reason for Appeal |
| D2790 |
| S |
| Crown - full cast high noble metal |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2791 |
| N |
| Crown - full cast predominantly base metal |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2792 |
| S |
| Crown - full cast noble metal |
| BWX and PA per unit |
| Narrative/Reason for Appeal & PA cemented restoration: BWX & PA per unit |
| D2794 |
| S |
| Crown – titanium and titanium alloys |
| BWX and PA per unit |
| Narrative/Reason for Appeal & BWX & PA per unit |
| D2799 |
| S |
| Provisional crown– further treatment or completion of diagnosis necessary prior to final impression |
| BWX and PA per unit |
| Narrative/Reason for Appeal &: BWX & PA per unit |
| D2910 |
| R |
| Recement or rebond inlay, onlay, veneer or partial coverage restoration |
| PA per unit |
| Narrative/Reason for Appeal & PA per unit |
| D2915 |
| S |
| Recement or rebond indirectly fabricated or prefabricated post and core |
| PA per unit |
| Narrative/Reason for Appeal & PA per unit |
| D2920 |
| R |
| Recement or rebond crown |
| PA per unit |
| Narrative/Reason for Appeal & PA per unit |
| D2921 |
| E |
| Reattachment of tooth fragment, incisal edge or cusp |
| N/A |
| Narrative/Reason for Appeal |
| D2929 |
| N |
| Prefabricated porcelain/ceramic crown – primary tooth |
| N/A |
| Narrative/Reason for Appeal |
| D2930 |
| N |
| Prefabricated stainless steel crown – primary tooth |
| N/A |
| Narrative/Reason for Appeal |
| D2931 |
| S |
| Prefabricated stainless steel crown - permanent tooth |
| PA per unit |
| Narrative/Reason for Appeal & PA per unit |
| D2932 |
| N |
| Prefabricated resin crown |
| N/A |
| Narrative/Reason for Appeal |
| D2933 |
| N |
| Prefabricated stainless steel crown with resin window |
| N/A |
| Narrative/Reason for Appeal |
| D2940 |
| E |
| Protective restoration |
| BWX or PA & Narrative |
| Narrative/Reason for Appeal &: BWX & PA |
| D2941 |
| N |
| Interim therapeutic restoration-primary dentition |
| N/A |
| Narrative/Reason for Appeal |
| D2949 |
| S |
| Restorative foundation for an indirect restoration |
| BWX or PA and Narrative |
| Narrative/Reason for Appeal &: BWX & PA |
| D2950 |
| S |
| Core buildup, including any pins when required |
| BWX and PA |
| Narrative/Reason for Appeal &: BWX & PA |
| D2951 |
| R |
| Pin retention - per tooth, in addition to restoration |
| BWX or PA |
| Narrative/Reason for Appeal &: BWX & PA |
| D2952 |
| S |
| Post and core in addition to crown, indirectly fabricated |
| PA per unit |
| Narrative/Reason for Appeal &: PA per unit |
| D2953 |
| N |
| Each additional indirectly fabricated post - same tooth |
| PA per unit |
| Narrative/Reason for Appeal &: PA per unit |
| D2954 |
| S |
| Prefabricated post and core in addition to crown |
| PA per unit |
| Narrative/Reason for Appeal &: PA per unit |
| D2955 |
| S |
| Post removal |
| PA per unit |
| Narrative/Reason for Appeal &: PA per unit |
| D2957 |
| N |
| Each additional prefabricated post - same tooth |
| PA |
| Narrative/Reason for Appeal &: PA |
| D2960 |
| N |
| Labial veneer (resin laminate) – chairside |
| N/A |
| Narrative/Reason for Appeal |
| D2961 |
| N |
| Labial veneer (resin laminate) - laboratory |
| N/A |
| Narrative/Reason for Appeal |
| D2962 |
| N |
| Labial veneer (porcelain laminate) - laboratory |
| N/A |
| Narrative/Reason for Appeal |
| D2971 |
| S |
| Additional procedures to construct new crown under existing partial denture framework |
| PA, Narrative |
| Narrative/Reason for Appeal & PA & Narrative |
| D2975 |
| S |
| Coping |
| PA and Full Mouth X-ray (FMX) or Pano |
| Narrative/Reason for Appeal & PA & FMX or Pano |
| D2980 |
| R |
| Crown repair, necessitated by restorative material failure |
| PA and narrative |
| Narrative/Reason for Appeal & PA |
| D2981 |
| N |
| Inlay repair necessitated by restorative material failure |
| N/A |
| Narrative/Reason for Appeal |
| D2982 |
| N |
| Onlay repair necessitated by restorative material failure |
| N/A |
| Narrative/Reason for Appeal |
| D2983 |
| N |
| Veneer repair necessitated by restorative material failure |
| N/A |
| Narrative/Reason for Appeal |
| D2990 |
| S |
| Resin infiltration of incipient smooth surface lesions |
| BWX or narrative |
| Narrative/Reason for Appeal & BWX |
| D2999 |
| N |
| Unspecified restorative procedure, by report |
| N/A |
| Narrative/Reason for Appeal |
| D3110 |
| N |
| Pulp cap direct (excluding final restoration) |
| PA |
| Narrative/Reason for Appeal & PA |
| D3120 |
| N |
| Pulp cap indirect (excluding final restoration) |
| N/A |
| Narrative/Reason for Appeal |
| D3220 |
| R |
| Therapeutic pulpotomy (excluding final restoration) |
| PA |
| Narrative/Reason for Appeal & PA |
| D3221 |
| R |
| Gross pulpal debridement, primary and permanent teeth |
| PA |
| Narrative/Reason for Appeal & PA |
| D3222 |
| S |
| Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development |
| PA |
| Narrative/Reason for Appeal & PA |
| D3230 |
| S |
| Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) |
| PA |
| Narrative/Reason for Appeal & PA |
| D3240 |
| S |
| Pulpal therapy (resorbable filling) – posterior, primary tooth excluding final restoration) |
| PA |
| Narrative/Reason for Appeal & PA |
| D3310 |
| E |
| Endodontic therapy - anterior (excluding final restoration) |
| PA for routine endo / emergency endo does not require preauthorization |
| Narrative/Reason for Appeal & PA Root Canal Fill: PA for routine endo/emergency does not require preauthorization |
| D3320 |
| E |
| Endodontic therapy – premolar tooth (excluding final restoration) |
| PA for routine endo / emergency endo does not require preauthorization |
| Narrative/Reason for Appeal & PA Root Canal Fill: PA for routine endo/emergency does not require preauthorization |
| D3330 |
| E |
| Endodontic therapy - molar (excluding final restoration) |
| PA for routine endo / emergency endo does not require preauthorization |
| Narrative/Reason for Appeal & PA Root Canal Fill: PA for routine endo/emergency does not require preauthorization |
| D3331 |
| S |
| Treatment of root canal obstruction; non-surgical access |
| PA |
| Narrative/Reason for Appeal & PA |
| D3332 |
| S |
| Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth |
| PA |
| Narrative/Reason for Appeal & PA |
| D3333 |
| S |
| Internal root repair of perforation defects |
| PA |
| Narrative/Reason for Appeal & PA |
| D3346 |
| S |
| Retreatment of previous root canal therapy - anterior |
| PA |
| Narrative/Reason for Appeal & PA Root Canal Fill: PA |
| D3347 |
| S |
| Retreatment of previous root canal therapy - premolar |
| PA |
| Narrative/Reason for Appeal & PA Root Canal Fill: PA |
| D3348 |
| S |
| Retreatment of previous root canal therapy - molar |
| PA |
| Narrative/Reason for Appeal & PA Root Canal Fill: PA |
| D3351 |
| S |
| Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) |
| PA |
| Narrative/Reason for Appeal & PA |
| D3352 |
| S |
| Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection etc.) |
| PA |
| Narrative/Reason for Appeal & PA |
| D3353 |
| S |
| Apexification/recalcification - final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.) |
| PA |
| Narrative/Reason for Appeal & PA |
| D3355 |
| S |
| Pulpal regeneration – initial visit |
| PA |
| Narrative/Reason for Appeal & PA |
| D3356 |
| S |
| Pulpal regeneration – interim medication replacement |
| PA |
| Narrative/Reason for Appeal & PA |
| D3357 |
| S |
| Pulpal regeneration-completion of treatment |
| PA |
| Narrative/Reason for Appeal & PA |
| D3410 |
| S |
| Apicoectomy - anterior |
| PA |
| Narrative/Reason for Appeal & PA |
| D3421 |
| S |
| Apicoectomy - premolar (first root) |
| PA |
| Narrative/Reason for Appeal & PA |
| D3425 |
| S |
| Apicoectomy - molar (first root) |
| PA |
| Narrative/Reason for Appeal & PA |
| D3426 |
| S |
| Apicoectomy (each additional root) |
| PA |
| Narrative/Reason for Appeal & PA |
| D3427 |
| S |
| Periradicular surgery without apicoectomy |
| PA |
| Narrative/Reason for Appeal & PA |
| D3428 |
| S |
| Bone graft in conjunction with periradicular surgery – per tooth, single site |
| PA |
| Narrative/Reason for Appeal & PA |
| D3429 |
| S |
| Bone graft in conjunction with periradicular surgery – each additional contiguous tooth in the same surgical site |
| PA |
| Narrative/Reason for Appeal & PA |
| D3430 |
| S |
| Retrograde filling - per root |
| PA |
| Narrative/Reason for Appeal & PA |
| D3431 |
| S |
| Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery |
| PA |
| Narrative/Reason for Appeal & PA |
| D3432 |
| S |
| Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery |
| PA |
| Narrative/Reason for Appeal & PA |
| D3450 |
| S |
| Root amputation - per root |
| PA |
| Narrative/Reason for Appeal & PA |
| D3460 |
| N |
| Endodontic endosseous implant |
| PA |
| Narrative/Reason for Appeal & PA |
| D3470 |
| S |
| Intentional reimplantation (including necessary splinting) |
| PA |
| Narrative/Reason for Appeal & PA |
| D3910 |
| S |
| Surgical procedure for isolation of tooth with rubber dam |
| PA |
| Narrative/Reason for Appeal & PA |
| D3920 |
| S |
| Hemisection (including any root removal), not including root canal therapy |
| PA |
| Narrative/Reason for Appeal & PA |
| D3950 |
| S |
| Canal preparation and fitting of preformed dowel or post |
| PA |
| Narrative/Reason for Appeal & PA |
| D3999 |
| N |
| Unspecified endodontic procedure, by report |
| N/A |
| Narrative/Reason for Appeal |
| D4210 |
| S |
| Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant |
| FMX, Perio Charting & Color Photographs |
| Narrative/Reason for Appeal & FMX, & Perio Charting & Color Photograph |
| D4211 |
| S |
| Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant |
| FMX, Perio Charting & Color Photographs |
| Narrative/Reason for Appeal & FMX, Perio Charting & Color Photographs |
| D4212 |
| N |
| Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth |
| N/A |
| Narrative/Reason for Appeal |
| D4230 |
| S |
| Anatomical crown exposure – four or more contiguous teeth per quadrant |
| FMX, Perio Charting, Narrative & Color Photographs |
| Narrative/Reason for Appeal, FMX, Perio Charting, & Color Photographs |
| D4231 |
| S |
| Anatomical crown exposure – one to three teeth or tooth bounded spaces per quadrant |
| FMX, Perio Charting, Narrative & Color Photographs |
| Narrative/Reason for Appeal, FMX, Perio Charting, & Color Photographs |
| D4240 |
| S |
| Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant |
| FMX & Perio Charting with Clinical Attachment Loss (CAL), & Narrative/Diagnosis |
| Narrative/Reason for Appeal, FMX & Perio Charting with CAL, & Narrative/Diagnosis |
| D4241 |
| S |
| Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant |
| FMX & Perio Charting with CAL, & Narrative/Diagnosis |
| Narrative/Reason for Appeal, FMX and Post-Treatment PA or Vertical Bitewing & Perio Charting with CAL |
| D4245 |
| S |
| Apically positioned flap |
| FMX & Perio Charting, Narrative, Color Photographs |
| Narrative/Reason for Appeal, FMX & Perio Charting with CAL |
| D4249 |
| S |
| Clinical crown lengthening - hard tissue |
| PA or FMX & Perio Charting |
| Narrative/Reason for Appeal & PA or FMX & Perio Charting |
| D4260 |
| S |
| Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant |
| PA or FMX, Perio Charting, & Narrative |
| Narrative/Reason for Appeal, PA or FMX, & Perio Charting |
| D4261 |
| S |
| Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant |
| PA or FMX & Perio Charting |
| Narrative/Reason for Appeal & PA or FMX & Perio Charting |
| D4263 |
| S |
| Bone replacement graft – retained natural tooth - first site in quadrant |
| FMX or Vertical Bitewing, Perio Charting with CAL, Narrative to include type of material, & smoking status |
| Narrative/Reason for Appeal & FMX or Vertical Bitewing, Perio Charting with CAL, Narrative to include type of material, & smoking status |
| D4264 |
| S |
| Bone replacement graft – retained natural tooth - each additional site in quadrant |
| FMX or Vertical Bitewing, Perio Charting, Narrative to include type of material, & smoking status |
| Narrative/Reason for Appeal & FMX or Vertical Bitewings, Perio Charting, Narrative to include type of material, & smoking status |
| D4265 |
| S |
| Biologic materials to aid in soft and osseous tissue regeneration |
| FMX or Vertical Bitewing, Perio Charting, Narrative to include type of material, & smoking status |
| Narrative/Reason for Appeal & FMX or Vertical Bitewing, Perio Charting, Narrative to include type of material, & smoking status |
| D4266 |
| S |
| Guided tissue regeneration - resorbable barrier, per site |
| FMX or Vertical Bitewing, Perio Charting, Narrative to include type of material, & smoking status |
| Narrative/Reason for Appeal, FMX or Vertical Bitewing, Perio Charting, Narrative to include type of material, & smoking status |
| D4267 |
| S |
| Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) |
| FMX or Vertical Bitewing, Perio Charting, Narrative to include type of material, & smoking status |
| Narrative/Reason for Appeal, FMX or Vertical Bitewing, Perio Charting, Narrative to include type of material, & smoking status |
| D4268 |
| S |
| Surgical revision procedure, per tooth |
| FMX or Vertical Bitewing, Perio Charting, Narrative to include type of material, & smoking status |
| Narrative/Reason for Appeal, FMX or Vertical Bitewing, Perio Charting, Narrative to include type of material, & smoking status |
| D4270 |
| S |
| Pedicle soft tissue graft procedure |
| FMX or Vertical Bitewing, Perio Charting, Narrative, Color Photograph, & smoking status |
| Narrative/Reason for Appeal & FMX or Vertical Bitewing, Perio Charting, Narrative, Color Photograph, & smoking status |
| D4273 |
| S |
| Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft |
| FMX or Vertical Bitewing, Perio Charting, Narrative, Color Photographs, & smoking status |
| Narrative/Reason for Appeal, FMX or Vertical Bitewing, Perio Charting, Color Photographs, & smoking status |
| D4274 |
| S |
| Mesial distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) |
| Pano or FMX or PA Perio Charting, & Narrative |
| Narrative/Reason for Appeal & Pano or FMX or PA Perio Charting, & Narrative/Diagnosis |
| D4275 |
| S |
| Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft |
| FMX or Vertical Bitewing, Perio Charting, Narrative to include type of material, Color Photographs, & smoking status |
| Narrative/Reason for Appeal, FMX or Vertical Bitewing, Perio Charting, Narrative to include type of material, Color Photographs, & smoking status |
| D4276 |
| S |
| Combined connective tissue and double pedicle graft, per tooth |
| FMX or Vertical Bitewing, Perio Charting, Narrative, Color Photographs, & smoking status |
| Narrative/Reason for Appeal, FMX or Vertical Bitewing, Perio Charting, Color Photographs, & smoking status |
| D4277 |
| S |
| Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth, implant, or dentulous tooth position in graft |
| FMX or Vertical Bitewing, Perio Charting, Narrative, Color Photographs, & smoking status |
| Narrative/Reason for Appeal, FMX or Vertical Bitewing, Perio Charting, Color Photographs, & smoking status |
| D4278 |
| S |
| Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, implant or edentulous tooth position in same graft site |
| FMX or Vertical Bitewing, Perio Charting, Narrative, Color Photographs, & smoking status |
| Narrative/Reason for Appeal, FMX or Vertical Bitewing, Perio Charting, Color Photographs, & smoking status |
| D4283 |
| S |
| Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site |
| FMX or Vertical Bitewing, Perio Charting, Narrative, Color Photographs, & smoking status |
| Narrative/Reason for Appeal, FMX or Vertical Bitewing, Perio Charting, Color Photographs, & smoking status |
| D4285 |
| S |
| Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – Each additional contiguous tooth, implant, or edentulous tooth position in same graft site |
| FMX or Vertical Bitewing, Perio Charting, Narrative, Color Photographs, & smoking status |
| Narrative/Reason for Appeal, FMX or Vertical Bitewing, Perio Charting, Color Photographs, & smoking status |
| D4320 |
| S |
| Provisional splinting - intracoronal |
| FMX, Perio Charting with CAL and mobility, & narrative |
| Narrative/Reason for Appeal, FMX, Perio Charting with CAL and mobility |
| D4321 |
| S |
| Provisional splinting - extracoronal |
| FMX, Perio Charting with CAL and mobility, & narrative |
| Narrative/Reason for Appeal, FMX, Perio Charting with CAL and mobility |
| D4341 |
| S |
| Periodontal scaling and root planing – four or more teeth per quadrant |
| FMX & Perio Charting |
| Narrative/Reason for Appeal & FMX & Perio Charting |
| D4342 |
| S |
| Periodontal scaling and root planing – one to three teeth per quadrant |
| FMX & Perio Charting |
| Narrative/Reason for Appeal & FMX & Perio Charting |
| D4346 |
| S |
| Scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluation |
| FMX & Perio Charting |
| Narrative/Reason for Appeal & FMX & Perio Charting |
| D4355 |
| R |
| Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit |
| Pano or FMX & Perio Charting |
| Narrative/Reason for Appeal & Pano or FMX, & Perio Charting |
| D4381 |
| N |
| Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth |
| N/A |
| Narrative/Reason for Appeal |
| D4910 |
| R |
| Periodontal maintenance |
| Pano or FMX & Perio Charting |
| Narrative/Reason for Appeal & Pano or FMX, & Perio Charting |
| D4920 |
| R |
| Unscheduled dressing change (by someone other than treating dentist or their staff) |
| Narrative |
| Narrative/Reason for Appeal |
| D4921 |
| N |
| Gingival irrigation-per quadrant |
| N/A |
| Narrative/Reason for Appeal |
| D4999 |
| N |
| Unspecified periodontal procedure, by report |
| N/A |
| Narrative/Reason for Appeal |
| D5110 |
| S |
| Complete denture - maxillary |
| Pano |
| Narrative/Reason for Appeal & Pano |
| D5120 |
| S |
| Complete denture - mandibular |
| Pano |
| Narrative/Reason for Appeal & Pano |
| D5130 |
| S |
| Immediate denture - maxillary |
| Pano |
| Narrative/Reason for Appeal & Pano |
| D5140 |
| S |
| Immediate denture - mandibular |
| Pano |
| Narrative/Reason for Appeal & Pano |
| D5211 |
| S |
| Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) |
| Pano or FMX |
| Narrative/Reason for Appeal & Pano or FMX |
| D5212 |
| S |
| Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) |
| Pano or FMX |
| Narrative/Reason for Appeal & Pano or FMX |
| D5213 |
| S |
| Maxillary partial denture - cast metal framework with resin denture bases (including retentive clasping materials, rests and teeth) |
| Pano or FMX |
| Narrative/Reason for Appeal & Pano or FMX |
| D5214 |
| S |
| Mandibular partial denture - cast metal framework with resin denture bases (including retentive clasping materials, rests and teeth) |
| Pano or FMX |
| Narrative/Reason for Appeal & Pano or FMX |
| D5221 |
| S |
| Immediate maxillary partial denture – resin base (including retentive clasping materials, rests and teeth) |
| Pano or FMX |
| Narrative/Reason for Appeal & Pano or FMX |
| D5222 |
| S |
| Immediate mandibular partial denture – resin base (including retentive clasping materials, rests and teeth) |
| Pano or FMX |
| Narrative/Reason for Appeal & Pano or FMX |
| D5223 |
| S |
| Immediate maxillary partial denture – cast metal framework with resin denture bases (including retentive clasping materials s, rests and teeth) |
| Pano or FMX |
| Narrative/Reason for Appeal & Pano or FMX |
| D5224 |
| S |
| Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive clasping materials, rests and teeth) |
| Pano or FMX |
| Narrative/Reason for Appeal & Pano or FMX |
| D5225 |
| S |
| Maxillary partial denture – flexible base (including any clasps, rests and teeth) |
| Pano or FMX |
| Narrative/Reason for Appeal & Pano or FMX |
| D5226 |
| S |
| Mandibular partial denture – flexible base (including any clasps, rests and teeth) |
| Pano or FMX |
| Narrative/Reason for Appeal & Pano or FMX |
| D5282 |
| N |
| Removable unilateral partial denture – one piece cast metal (including clasps and teeth), maxillary |
| N/A |
| Narrative/Reason for Appeal |
| D5283 |
| N |
| Removable unilateral partial denture – one piece cast metal (including clasps and teeth), mandibular |
| N/A |
| Narrative/Reason for Appeal |
| D5284 |
| N |
| Removable unilateral partial denture – one piece flexible base (including clasps and teeth) – per quadrant |
| N/A |
| Narrative/Reason for Appeal |
| D5286 |
| N |
| Removable unilateral partial denture – one piece resin (including clasps and teeth) – per quadrant |
| N/A |
| Narrative/Reason for Appeal |
| D5410 |
| R |
| Adjust complete denture - maxillary |
| Narrative |
| Narrative/Reason for Appeal |
| D5411 |
| R |
| Adjust complete denture - mandibular |
| Narrative |
| Narrative/Reason for Appeal |
| D5421 |
| R |
| Adjust partial denture - maxillary |
| Narrative |
| Narrative/Reason for Appeal |
| D5422 |
| R |
| Adjust partial denture - mandibular |
| Narrative |
| Narrative/Reason for Appeal |
| D5511 |
| R |
| Repair broken complete denture base - mandibular |
| Narrative |
| Narrative/Reason for Appeal |
| D5512 |
| R |
| Repair broken complete denture base – maxillary |
| Narrative |
| Narrative/Reason for Appeal |
| D5520 |
| R |
| Replace missing or broken teeth - complete denture (each tooth) |
| Narrative |
| Narrative/Reason for Appeal |
| D5611 |
| R |
| Repair resin partial denture base - mandibular |
| Narrative |
| Narrative/Reason for Appeal |
| D5612 |
| R |
| Repair resin partial denture base – maxillary |
| Narrative |
| Narrative/Reason for Appeal |
| D5621 |
| R |
| Repair cast partial framework - mandibular |
| Narrative |
| Narrative/Reason for Appeal |
| D5622 |
| R |
| Repair cast partial framework – maxillary |
| Narrative |
| Narrative/Reason for Appeal |
| D5630 |
| R |
| Repair or replace broken retentive clasping materials – per tooth |
| Narrative |
| Narrative/Reason for Appeal |
| D5640 |
| R |
| Replace broken teeth - per tooth |
| Narrative |
| Narrative/Reason for Appeal |
| D5650 |
| S |
| Add tooth to existing partial denture |
| Pano or FMX & Narrative |
| Narrative/Reason for Appeal & Pano or FMX |
| D5660 |
| S |
| Add clasp to existing partial denture – per tooth |
| Pano or FMX & Narrative |
| Narrative/Reason for Appeal & Pano or FMX |
| D5670 |
| S |
| Replace all teeth and acrylic on cast metal framework (maxillary) |
| Pano or FMX & Narrative |
| Narrative/Reason for Appeal & Pano or FMX |
| D5671 |
| S |
| Replace all teeth and acrylic on cast metal framework (mandibular) |
| Pano or FMX & Narrative |
| Narrative/Reason for Appeal & Pano or FMX |
| D5710 |
| S |
| Rebase complete maxillary denture |
| Pano & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5711 |
| S |
| Rebase complete mandibular denture |
| Pano & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5720 |
| S |
| Rebase maxillary partial denture |
| Pano or FMX & Narrative |
| Narrative/Reason for Appeal & Pano or FMX |
| D5721 |
| S |
| Rebase mandibular partial denture |
| Pano or FMX & Narrative |
| Narrative/Reason for Appeal & Pano or FMX |
| D5730 |
| S |
| Reline complete maxillary denture (chairside) |
| Pano & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5731 |
| S |
| Reline complete mandibular denture (chairside) |
| Pano & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5740 |
| S |
| Reline maxillary partial denture (chairside) |
| Pano or FMX & Narrative |
| Narrative/Reason for Appeal & Pano or FMX |
| D5741 |
| S |
| Reline mandibular partial denture (chairside) |
| Pano or FMX |
Narrative Narrative/Reason for Appeal & Pano or FMX
| D5750 |
| S |
| Reline complete maxillary denture (laboratory) |
| Pano & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5751 |
| S |
| Reline complete mandibular denture (laboratory) |
| Pano & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5760 |
| S |
| Reline maxillary partial denture (laboratory) |
| Pano or FMX & Narrative |
| Narrative/Reason for Appeal & Pano or FMX |
| D5761 |
| S |
| Reline mandibular partial denture (laboratory) |
| Pano or FMX & Narrative |
| Narrative/Reason for Appeal & Pano or FMX |
| D5810 |
| S |
| Interim complete denture (maxillary) |
| Pano & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5811 |
| S |
| Interim complete denture (mandibular) |
| Pano & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5820 |
| S |
| Interim partial denture (maxillary) |
| Pano or FMX & Narrative |
| Narrative/Reason for Appeal & Pano or FMX |
| D5821 |
| S |
| Interim partial denture (mandibular) |
| Pano or FMX & Narrative |
| Narrative/Reason for Appeal & Pano or FMX |
| D5850 |
| R |
| Tissue conditioning, maxillary |
| Narrative |
| Narrative/Reason for Appeal |
| D5851 |
| R |
| Tissue conditioning, mandibular |
| Narrative |
| Narrative/Reason for Appeal |
| D5862 |
| S |
| Precision attachment, by report |
| Narrative |
| Narrative/Reason for Appeal |
| D5863 |
| S |
| Overdenture – complete maxillary |
| Pano & PA of implants, & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5864 |
| S |
| Overdenture – partial maxillary |
| Pano & PA of implants, & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5865 |
| S |
| Overdenture – complete mandibular |
| Pano & PA of implants, & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5866 |
| S |
| Overdenture – partial mandibular |
| Pano & PA of implants, & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5867 |
| S |
| Replacement of replaceable part of semi-precision attachment (male or female component) |
| Pano & PA of implants, & Narrative |
| Narrative/Reason for Appeal |
| D5875 |
| S |
| Modification of removable prosthesis following implant surgery |
| Pano & PA of implants, & Narrative |
| Narrative/Reason for Appeal |
| D5876 |
| S |
| Add metal substructure to acrylic full denture (per arch) |
| Narrative |
| Narrative/Reason for Appeal |
| D5899 |
| N |
| Unspecified removable prosthodontics procedure, by report |
| N/A |
| Narrative/Reason for Appeal |
| D5911 |
| S |
| Facial moulage (sectional) |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5912 |
| S |
| Facial moulage (complete) |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5913 |
| S |
| Nasal prosthesis |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5914 |
| S |
| Auricular prosthesis |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5915 |
| S |
| Orbital prosthesis |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5916 |
| S |
| Ocular prosthesis |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5919 |
| S |
| Facial prosthesis |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5922 |
| S |
| Nasal septal prosthesis |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5923 |
| S |
| Ocular prosthesis, interim |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5924 |
| S |
| Cranial prosthesis |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5925 |
| S |
| Facial augmentation implant prosthesis |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5926 |
| S |
| Nasal prosthesis, replacement |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5927 |
| S |
| Auricular prosthesis, replacement |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5928 |
| S |
| Orbital prosthesis, replacement |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5929 |
| S |
| Facial prosthesis, replacement |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5931 |
| S |
| Obturator prosthesis, surgical |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5932 |
| S |
| Obturator prosthesis, definitive |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5933 |
| S |
| Obturator prosthesis, modification |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5934 |
| S |
| Mandibular resection prosthesis with guide flange |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5935 |
| S |
| Mandibular resection prosthesis without guide flange |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5936 |
| S |
| Obturator prosthesis, interim |
| Appropriate radiographic image or photos & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5937 |
| S |
| Trismus appliance (not for TMD treatment) |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5953 |
| S |
| Speech aid prosthesis, adult |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5954 |
| S |
| Palatal augmentation prosthesis |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5955 |
| S |
| Palatal lift prosthesis, definitive |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5958 |
| S |
| Palatal lift prosthesis, interim |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5959 |
| S |
| Palatal lift prosthesis, modification |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5960 |
| S |
| Speech aid prosthesis, modification |
| Narrative |
| Narrative/Reason for Appeal |
| D5982 |
| S |
| Surgical stent |
| Pano & Narrative |
| Narrative/Reason for Appeal & Pano |
| D5983 |
| S |
| Radiation carrier |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5984 |
| S |
| Radiation shield |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5985 |
| S |
| Radiation cone locator |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5986 |
| S |
| Fluoride gel carrier |
| Pano &Narrative |
| Narrative/Reason for Appeal & Pano |
| D5987 |
| S |
| Commissure splint |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5988 |
| S |
| Surgical splint |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5991 |
| S |
| Vesiculobullous disease medicament carrier |
| Narrative & Color Photographs |
| Narrative/Reason for Appeal |
| D5992 |
| S |
| Adjust maxillofacial prosthetic appliance |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5993 |
| S |
| Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments, by report |
| Appropriate radiographic image & Narrative |
| Narrative/Reason for Appeal & appropriate radiographic image |
| D5994 |
| N |
| Periodontal medicament carrier with peripheral seal-laboratory processed |
| N/A |
| Narrative/Reason for Appeal |
| D5999 |
| N |
| Unspecified maxillofacial prosthesis, by report |
| N/A |
| Narrative/Reason for Appeal |
| D6010 |
| S |
| Surgical placement of implant body: endosteal implant |
| PA & Pano or FMX or Other appropriate radiographic image |
- Brand of implant compatible with Nobel Biocare and 3i in the area of abutment configuration & screw thread design
- Mesial-distal and buccal lingual dimensions of ridge
- Vertical restorative space -Smoking Status
- Time tooth missing
- Command memorandum showing 12 month eligibility Narrative/Reason for Appeal & Pano or FMX or Other appropriate radiographic image
- Brand of implant placed showing compatibility of surgical implant system with Nobel Biocare and 3i in the area of abutment configuration & screw thread design
- Smoking Status
- Time tooth missing
- Command memorandum showing 12 month eligibility
| D6011 |
| S |
| Second stage implant surgery |
| PA & Pano or FMX or Other appropriate radiographic image |
| Narrative/Reason for Appeal, PA & Pano or FMX or Other appropriate radiographic image |
| D6012 |
| S |
| Surgical placement of interim implant body for transitional prosthesis: endosteal implant |
| PA & Pano or FMX or Other appropriate radiographic image |
| Narrative/Reason for Appeal, PA & Pano or FMX or Other appropriate radiographic image |
| D6013 |
| N |
| Surgical placement of mini-implant |
| PA & Pano or FMX or Other appropriate radiographic image |
| Narrative/Reason for Appeal, PA & Pano or FMX or Other appropriate radiographic image |
| D6040 |
| S |
| Surgical placement: eposteal implant |
| Pano or FMX or Other appropriate radiographic image |
| Narrative/Reason for Appeal & Pano or FMX or Other appropriate radiographic image |
| D6050 |
| S |
| Surgical placement: transosteal implant |
| Pano or FMX or Other appropriate radiographic image |
| Narrative/Reason for Appeal & Pano or FMX or Other appropriate radiographic image |
| D6051 |
| S |
| Interim abutment |
| PA & Pano or FMX or Other appropriate radiographic image |
| Narrative/Reason for Appeal |
| D6052 |
| S |
| Semi-precision attachment abutment |
| PA & Pano or FMX or Other appropriate radiographic image |
| Narrative/Reason for Appeal & PA & Pano or FMX or Other appropriate radiographic image |
| D6055 |
| S |
| Dental implant supported connecting bar |
| PA & Pano or FMX |
| Narrative/Reason for Appeal, PA & Pano or FMX |
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