PA not required in the following circumstances:

1. For hospital or ASC POS.
2. In an emergency.¹
3. For children (ages 0-20), when performed by an oral surgeon or pediatric dentist.

Reimbursement maximum is 15 minutes.
Not billable to the member.
Bill only D9222 and D9223 for general anesthesia.
Not payable with D9230, D9243, or D9248.

PA not required in the following circumstances:

1. For hospital or ASC POS.
2. In an emergency.¹
3. For children (ages 0-20), when performed by an oral surgeon or pediatric dentist.

Reimbursement maximum is 30 minutes (two 15-minute unit increments).
Not billable to the member.
Bill only D9222 and D9223 for general anesthesia.
Not payable with D9230, D9243, or D9248.

PA not required in the following circumstances:

1. For hospital or ASC POS.
2. In an emergency.¹
3. For children (ages 0-20), when performed by an oral surgeon or pediatric dentist.

Reimbursement maximum is 15 minutes.
Not billable to the member.
Bill only D9239 and D9243 for intravenous sedation.
Not payable with D9223, D9230, or D9248.

PA not required in the following circumstances:

1. For hospital or ASC POS.
2. In an emergency.¹
3. For children (ages 0-20), when performed by an oral surgeon or pediatric dentist.

Reimbursement maximum is 30 minutes (two 15-minute unit increments).
Not billable to the member.
Bill only D9239 and D9243 for intravenous sedation.
Not payable with D9223, D9230, or D9248.

Complete Dentures (Including Routine Post-Delivery Care)

D5110

Complete denture — maxillary

Yes

Allowed once per five years.^{1, 2}

D5120

Complete denture — mandibular

Yes

Allowed once per five years.^{1, 2}

Partial Dentures (Including Routine Post-Delivery Care)

D5211

Maxillary (upper) partial denture; resin base (including any conventional clasps, rests and teeth)

Yes

Allowed once per five years.^{1, 2}

D5212

Mandibular (lower) partial denture; resin base (including any conventional clasps, rests and teeth)

Yes

Allowed once per five years.^{1, 2}

D5213

Maxillary partial denture; cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

Yes

Allowed once per five years.^{1, 2} Reimbursement is limited to reimbursement for D5211. Upgraded partial denture. No dentist is obligated to complete this type of partial.

D5214

Mandibular partial denture; cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

Yes

Allowed once per five years.^{1, 2} Reimbursement is limited to reimbursement for D5212. Upgraded partial denture. No dentist is obligated to complete this type of partial.

D5225

Maxillary partial denture — flexible base (including any clasps, rests and teeth)

Yes

Allowed once per five years.^{1, 2}

D5226

Mandibular partial denture — flexible base (including any clasps, rests and teeth)

Yes

Allowed once per five years.^{1, 2}

Repairs to Complete Dentures

D5511

Repair broken complete denture base, mandibular

No

Combined maximum reimbursement limit per six months for repairs.

D5512

Repair broken complete denture base, maxillary

No

Combined maximum reimbursement limit per six months for repairs.

D5520

Replace missing or broken teeth — complete denture (each tooth)

No

Combined maximum reimbursement limit per six months for repairs.

Repairs to Partial Dentures

D5611

Repair resin partial denture base, mandibular

No

Combined maximum reimbursement limit per six months for repairs.

D5612

Repair resin partial denture base, maxillary

No

Combined maximum reimbursement limit per six months for repairs.

D5621

Repair cast partial framework, mandibular

No

Combined maximum reimbursement limit per six months for repairs.

D5622

Repair cast partial framework, maxillary

No

Combined maximum reimbursement limit per six months for repairs.

D5630

Repair or replace broken clasp — per tooth

No

Combined maximum reimbursement limit per six months for repairs.
Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.
Requires tooth numbers on claim submission.

D5640

Replace broken teeth — per tooth

No

Combined maximum reimbursement limit per six months for repairs.
Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.

D5650

Add tooth to existing partial denture

No

Combined maximum reimbursement limit per six months for repairs.
Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.

D5660

Add clasp to existing partial denture — per tooth

No

Combined maximum reimbursement limit per six months for repairs.
Requires an area of oral cavity code (01=Maxillary or 02=Mandibular) in the appropriate element of the claim form.
Requires tooth numbers on claim submission.

D5670

Replace all teeth and acrylic on cast metal framework (maxillary)

Yes

Combined maximum reimbursement limit per six months for repairs.
Requires area of oral cavity code 01=Maxillary in the appropriate element of the claim form.

D5671

Replace all teeth and acrylic on cast metal framework (mandibular)

Yes

Combined maximum reimbursement limit per six months for repairs.
Requires area of oral cavity code 02=Mandibular in the appropriate element of the claim form.

Denture Reline Procedures

D5750

Reline complete maxillary denture (laboratory)

No

Allowed once per three years.¹
Retain documentation of medical necessity.

D5751

Reline complete mandibular denture (laboratory)

No

Allowed once per three years.¹
Retain documentation of medical necessity.

D5760

Reline maxillary partial denture (laboratory)

No

Allowed once per three years.¹
Retain documentation of medical necessity.

D5761

Reline mandibular partial denture (laboratory)

No

Allowed once per three years.¹
Retain documentation of medical necessity.

21076

Impression and custom preparation; surgical obturator prosthesis

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21077

Impression and custom preparation; orbital prosthesis

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21079

Impression and custom preparation; interim obturator prosthesis

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21080

Impression and custom preparation; definitive obturator prosthesis

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21081

Impression and custom preparation; mandibular resection prosthesis

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21082

Impression and custom preparation; palatal augmentation prosthesis

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21083

Impression and custom preparation; palatal lift prosthesis

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21084

Impression and custom preparation; speech aid prosthesis

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21085

Impression and custom preparation; oral surgical splint

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21086

Impression and custom preparation; auricular prosthesis

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21087

Impression and custom preparation; nasal prosthesis

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21088

Impression and custom preparation; facial prosthesis

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

21089

Unlisted maxillofacial prosthetic procedure

Yes

Allowed once per six months.
Must be in an office setting.
Must be rendered by an oral surgeon, orthodontist, pediatric dentist or prosthodontist.
Medical necessity as determined by defect and prognosis must be demonstrated.
Refer to the Custom Preparation of Maxillofacial Prosthetics Online Handbook topic for limitations and requirements.

D5932

Obturator prosthesis, definitive

No

Allowed once per six months.¹
Retain documentation of medical necessity.

D5955

Palatal lift prosthesis, definitive

No

Allowed once per six months.¹
Retain documentation of medical necessity.

D5991

Topical medicament carrier

No

D5999

Unspecified maxillofacial prosthesis, by report

Yes

For medically necessary removable prosthodontic procedures.
Use this code only if a service is provided that is not accurately described by other HCPCS (Healthcare Common Procedure Code System) or CPT (Current Procedural Terminology) procedure codes.

Fixed Partial Denture Pontics

D6211

Pontic — cast predominantly base metal

Yes

Permanent teeth only (tooth numbers 1–32 and 51–82 only).

D6241

Pontic — porcelain fused to predominantly base metal

Yes

Permanent teeth only (tooth numbers 1–32 and 51–82 only).

Fixed Partial Denture Retainers — Inlays/Onlays

D6545

Retainer; cast metal for resin bonded fixed prosthesis

Yes

Tooth numbers 1–32, 51–82 only.

Fixed Partial Denture Retainers — Crowns

D6751

Retainer crown — porcelain fused to predominantly base metal

Yes

Permanent teeth only (tooth numbers 1–32 and 51–82 only).

D6791

Retainer crown — full cast predominantly base metal

Yes

Permanent teeth only (tooth numbers 1–32 and 51–82 only).

Other Fixed Partial Denture Services

D6930

Recement fixed partial denture

No

D6940

Stress breaker

Yes

Copy of lab bill required.

D6980

Fixed partial denture repair, by report

Yes

Copy of lab bill required.

D6985

Pediatric partial denture, fixed

No

Allowable up to age 12.
Retain documentation of medical necessity.

Extractions (Includes local anesthesia, suturing, if needed, and routine postoperative care)

D7111

Extraction, coronal remnants — primary tooth

No

Allowed only once per tooth.
Primary teeth only (tooth letters A–T and AS–TS only).
Not payable same DOS (date of service) as D7250 for same tooth letter.

D7140

Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

No

Allowed only once per tooth (tooth numbers 1–32, A–T, 51–82 and AS–TS).
Not payable same DOS as D7250 for same tooth number.

Surgical Extractions (Includes local anesthesia, suturing, if needed, and routine postoperative care)

D7210

Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated

No

Allowed only once per tooth.
Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹
Not payable same DOS as D7250 for same tooth number.

D7220

Removal of impacted tooth — soft tissue

No

Allowed only once per tooth.
Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹
Not payable same DOS as D7250 for the same tooth number.

D7230

Removal of impacted tooth — partially bony

No

Allowed only once per tooth.
Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹
Not payable same DOS as D7250 for the same tooth number.

D7240

Removal of impacted tooth — completely bony

No

Allowed only once per tooth.
Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹
Not payable same DOS as D7250 for the same tooth number.

D7241

Removal of impacted tooth — completely bony, with unusual surgical complications

No

Allowed only once per tooth.
Covered when performing an emergency service or for orthodontia (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹
Not payable same DOS as D7250 for the same tooth number.

D7250

Removal of residual tooth roots (cutting procedure)

No

Emergency only (tooth numbers 1–32, A–T, 51–82 and AS–TS).¹
Allowed only once per tooth.
Not allowed on the same DOS as tooth extraction of same tooth number.

Other Surgical Procedures

D7260 or CPT²

Oroantral fistula closure

No

Operative report required on claim submission.

D7261

Primary closure of a sinus perforation

No

Operative report required on claim submission.

D7270

Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth

No

Emergency only (tooth numbers 1–32, C–H, M–R, 51–82, CS–HS, and MS–RS).¹
Operative report required on claim submission.

D7280

Exposure of an unerupted tooth

No

Not allowed for primary or wisdom teeth (tooth numbers 2–15, 18–31, 52–65, and 68–81 only).
Allowable for members ages 0–20.
Covered for orthodontic reasons.
Clinical notes and an operative report must be retained in the member’s medical or dental record.

D7282

Mobilization of erupted or malpositioned tooth to aid eruption

No

Not allowed for primary or wisdom teeth (tooth numbers 2–15, 18–31, 52–65, and 68–81 only).
Allowable for members ages 0-20.
Covered for orthodontic reasons.
Clinical notes and an operative report must be retained in the member’s medical or dental record.

D7283

Placement of device to facilitate eruption of impacted tooth

No

Not allowed for primary or wisdom teeth (tooth numbers 2–15, 18–31, 52–65, and 68–81 only).
Allowable for members ages 0-20.
Covered for orthodontic reasons.
Clinical notes and an operative report must be retained in the member’s medical or dental record.

D7285 or CPT²

Incisional biopsy of oral tissue — hard (bone, tooth)

No

Once per DOS.³
Operative report required on claim submission.

D7286 or CPT²

Incisional biopsy of oral tissue — soft

No

Once per DOS.³
Operative report required on claim submission.

D7287 or CPT²

Exfoliative cytological sample collection

No

Once per DOS.³
Operative report required on claim submission.

D7288

Brush biopsy — transepithelial sample collection

No

Once per DOS.³
Operative report required on claim submission.

Alveoloplasty — Surgical Preparation of Ridge for Dentures

D7310

Alveoloplasty in conjuction with extractions — per quadrant

No

Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right).
X-ray, treatment notes and treatment plan required.

D7311

Alveoloplasty in conjuction with extractions — one to three teeth or tooth spaces, per quadrant

No

Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right).
X-ray, treatment notes and treatment plan required.

D7320

Alveoloplasty not in conjuction with extractions — per quadrant

No

Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right).
X-ray, treatment notes and treatment plan required.

D7321

Alveoloplasty not in conjuction with extractions — one to three teeth or tooth spaces, per quadrant

No

Allowable area of oral cavity codes: 10 (upper right), 20 (upper left), 30 (lower left), 40 (lower right).
X-ray, treatment notes and treatment plan required.

Surgical Excision of Soft Tissue Lesions

D7410 or CPT²

Excision of benign lesion up to 1.25 cm

No

Once per DOS.³
Pathology report required.

D7411 or CPT²

Excision of benign lesion greater than 1.25 cm

No

Once per DOS.³
Pathology report required.

D7412 or CPT²

Excision of benign lesion, complicated

No

Once per DOS.³
Pathology report required.

D7413 or CPT²

Excision of malignant lesion up to 1.25 cm

No

Once per DOS.³
Pathology report required.

D7414 or CPT²

Excision of malignant lesion greater than 1.25 cm

No

Once per DOS.³
Pathology report required.

D7415 or CPT²

Excision of malignant lesion, complicated

No

Once per DOS.³
Pathology report required.

Surgical Excision of Intra-Osseous Lesions

D7440 or CPT²

Excision of malignant tumor — lesion diameter up to 1.25 cm

No

Once per DOS.³
Pathology report required.

D7441 or CPT²

Excision of malignant tumor — lesion diameter greater than 1.25 cm

No

Once per DOS.³
Pathology report required.

D7450 or CPT²

Removal of benign odontogenic cyst or tumor — lesion diameter up to 1.25 cm

No

Once per DOS.³
Pathology report required.

D7451 or CPT²

Removal of benign odontogenic cyst or tumor — lesion diameter greater than 1.25 cm

No

Once per DOS.³
Pathology report required.

D7460 or CPT²

Removal of benign nonodontogenic cyst or tumor — lesion diameter up to 1.25 cm

No

Once per DOS.³
Pathology report required.

D7461 or CPT²

Removal of benign nonodontogenic cyst or tumor — lesion diameter greater than 1.25 cm

No

Once per DOS.³
Pathology report required.

Excision of Bone Tissue

D7471 or CPT²

Removal of lateral exostosis (maxilla or mandible)

Yes

Oral photographic image or diagnostic cast of arch required for PA.

D7472 or CPT²

Removal of torus palatinus

Yes

Oral photographic image or diagnostic cast of arch required for PA.

D7473 or CPT²

Removal of torus mandibularis

Yes

Oral photographic image or diagnostic cast of arch required for PA.

D7485 or CPT²

Surgical reduction of osseous tuberosity

No

Operative report required on claim submission.

D7490 or CPT²

Radical resection of maxilla or mandible

No

Operative report required on claim submission.
Only allowable in hospital or ambulatory surgical center POS (place of service).

Surgical Incision

D7510 or CPT²

Incision and drainage of abscess — intraoral soft tissue

No

Operative report required on claim submission.
Not to be used for periodontal abscess—use D9110.

D7511 or CPT²

Incision and drainage of abscess — intraoral soft tissue — complicated (includes drainage of multiple fascial spaces)

No

Operative report required on claim submission.
Not to be used for periodontal abscess—use D9110.

D7520 or CPT²

Incision and drainage of abscess — extraoral soft tissue

No

Operative report required on claim submission.

D7521 or CPT²

Incision and drainage of abscess — extraoral soft tissue — complicated (includes drainage of multiple fascial spaces)

No

Operative report required on claim submission.

D7530 or CPT²

Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue

No

Not allowed for removal of root fragments and bone spicules.
(Use D7250 instead.)
Operative report required on claim submission.

D7540 or CPT²

Removal of reaction producing foreign bodies, musculoskeletal system

No

Not allowed for removal of root fragments and bone spicules.
(Use D7250 instead.)
Operative report required on claim submission.

D7550 or CPT²

Partial ostectomy/sequestrectomy for removal of non-vital bone

No

Operative report required on claim submission.

D7560 or CPT²

Maxillary sinusotomy for removal of tooth fragment or foreign body

No

Operative report required on claim submission.

Treatment of Fractures — Simple

D7610 or CPT²

Maxilla — open reduction (teeth immobilized, if present)

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7620 or CPT²

Maxilla — closed reduction (teeth immobilized, if present)

No

Operative report required on claim submission.

D7630 or CPT²

Mandible — open reduction (teeth immobilized, if present)

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7640 or CPT²

Mandible — closed reduction (teeth immobilized, if present)

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7650 or CPT²

Malar and/or zygomatic arch — open reduction

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7660 or CPT²

Malar and/or zygomatic arch — closed reduction

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7670 or CPT²

Alveolus — closed reduction, may include stabilization of teeth

No

Operative report required on claim submission.

D7671 or CPT²

Alveolus — open reduction, may include stabilization of teeth

No

Operative report required on claim submission.

D7680 or CPT²

Facial bones — complicated reduction with fixation and multiple surgical approaches

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

Treatment of Fractures — Compound

D7710 or CPT²

Maxilla — open reduction

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7720 or CPT²

Maxilla — closed reduction

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7730 or CPT²

Mandible — open reduction

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7740 or CPT²

Mandible — closed reduction

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7750 or CPT²

Malar and/or zygomatic arch — open reduction

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7760 or CPT²

Malar and/or zygomatic arch — closed reduction

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7770 or CPT²

Alveolus — open reduction stabilization of teeth

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7771 or CPT²

Alveolus — closed reduction stabilization of teeth

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7780 or CPT²

Facial bones — complicated reduction with fixation and multiple approaches

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions

D7810 or CPT²

Open reduction of dislocation

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7820 or CPT²

Closed reduction of dislocation

No

Once per DOS.³
Operative report required on claim submission.

D7830 or CPT²

Manipulation under anesthesia

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7840 or CPT²

Condylectomy

Yes

Only allowable in hospital, office, or ambulatory surgical center POS.
No operative report required on claim submission.

D7850 or CPT²

Surgical discectomy, with/without implant

Yes

Only allowable in hospital, office, or ambulatory surgical center POS.
No operative report required on claim submission.

D7860 or CPT²

Arthrotomy

Yes

Only allowable in hospital, office, or ambulatory surgical center POS.
No operative report required on claim submission.

D7871 or CPT²

Non-arthroscopic lysis and lavage

Yes

Allowable only once per side (right and left) per three years.

D7899

Unspecified TMD therapy, by report

Yes

Use this code for billing TMJ (temporomandibular joint) assistant surgeon.
Procedure must be included in PA request for the surgery itself.
Only allowable in hospital or ambulatory surgical center POS.

Repair of Traumatic Wounds

D7910 or CPT²

Suture of recent small wounds up to 5 cm

No

Emergency only¹—operative report required on claim submission.
Once per DOS.³

Complicated Suturing (Reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure)

D7911 or CPT²

Complicated suture — up to 5 cm

No

Covered for trauma (emergency) situations only.¹
Once per DOS.³
Operative report required on claim submission.

D7912 or CPT²

Complicated suture — greater than 5 cm

No

Covered for trauma (emergency) situations only.¹
Once per DOS.³
Operative report required on claim submission.

Other Repair Procedures

D7940 or CPT²

Osteoplasty — for orthognathic deformities

Yes

Only allowable in hospital, office, or ambulatory surgical center POS.
No operative report required on claim submission.
Allowable age less than 21.

D7950 or CPT²

Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones — autogeneous or nonautogeneous, by report

Yes

Only allowable in hospital, office, or ambulatory surgical center POS.
No operative report required on claim submission.

D7951

Sinus augmentation with bone or bone substitutes

No

D7960 or CPT²

Frenulectomy (frenectomy or frenotomy) — separate procedure

No

Covered areas of the oral cavity are 01 and 02. The area of the oral cavity is required to be indicated on the claim.
Up to two units of service per area of the oral cavity allowed per DOS. Total of four units per DOS.
Note: An image of the obstructed frenum is not required to be submitted with claims but must be available in the medical or dental record. A dentist statement regarding the medical/dental need for the treatment is required to be available upon request.
Refer to the Frenulectomy Procedures Online Handbook topic for limitations and requirements.

D7970 or CPT²

Excision of hyperplastic tissue per arch

Yes

No operative report required on claim submission.

D7972 or CPT²

Surgical reduction of fibrous tuberosity

No

Operative report required on claim submission.

D7979

Non-surgical sialolithotomy

No

No operative report required on claim submission.

D7980 or CPT²

Surgical sialolithotomy

No

Only allowable in hospital, office, or ambulatory surgical center POS.
Operative report required on claim submission.

D7991 or CPT²

Coronoidectomy

Yes

Only allowable in hospital or ambulatory surgical center POS.
No operative report required on claim submission.

D7997 or CPT²

Appliance removal (not by dentist who placed appliance), includes removal of archbar

No

Operative report required on claim submission.

D7999 or CPT²

Unspecified oral surgery procedure, by report

Yes

For medically necessary unspecified oral surgery procedure, by report.
Use this code only if a service is provided that is not accurately described by other HCPCS or CPT procedure codes.
Note: For occlusal guard use procedure code D9440.

Limited Orthodontic Treatment

D8010

Limited orthodontic treatment of the primary dentition

Yes

Allowable age less than 21.

D8020

Limited orthodontic treatment of the transitional dentition

Yes

Allowable age less than 21.

D8030

Limited orthodontic treatment of the adolescent dentition

Yes

Allowable age less than 21.

D8040

Limited orthodontic treatment of the adult dentition

Yes

Allowable age less than 21.

Interceptive Orthodontic Treatment

D8050

Interceptive orthodontic treatment of the primary dentition

Yes

Allowable age less than 21.

D8060

Interceptive orthodontic treatment of the transitional dentition

Yes

Allowable age less than 21.

Comprehensive Orthodontic Treatment

D8070

Comprehensive orthodontic treatment of the transitional dentition

Yes

Allowable age less than 21.

D8080

Comprehensive orthodontic treatment of the adolescent dentition

Yes

Allowable age less than 21.

D8090

Comprehensive orthodontic treatment of the adult dentition

Yes

Allowable age less than 21.

Minor Treatment to Control Harmful Habits

D8210

Removable appliance therapy

Yes

Allowable age less than 21.

D8220

Fixed appliance therapy

Yes

Allowable age less than 21.

Other Orthodontic Services

D8660

Pre-orthodontic treatment visit

No

Allowable age less than 21.
Includes exam, diagnostic tests and consult.

D8670

Periodic orthodontic treatment visit (as part of contract)

Yes

Allowable age less than 21.
Used for monthly adjustments.

D8680

Orthodontic retention (removal of appliances, construction and placement of retainer[s])

Yes

Allowable age less than 21.

D8695

Removal of fixed orthodontic appliances for reasons other than completion of treatment

Yes

Covered for members ages 0 to 20 years.
Allowable once per member per provider.
Coverage is considered on a case-by-case basis with a review of the following requirements:

• Supporting documentation explaining the rationale for terminating existing treatment, including, but not limited to, clinical or member considerations.
• A signed statement showing the member’s, and/or member’s authorized representative, approval of the service.

D8698

re-cement or re-bond fixed retainer — maxillary

No

D8699

re-cement or re-bond fixed retainer — mandibular

No

D8703

replacement of lost or broken retainer — maxillary

No

Covered for members ages 0 to 20 years.

D8704

replacement of lost or broken retainer — mandibular

No

Covered for members ages 0 to 20 years.

Mesial

M

Facial

F

Incisal

I

Lingual

L

Distal

D

Gingival

G

Mesial

M

Bucal

B

Occlusal

O

Lingual

L

Distal

D

Gingival

G