If there is an extenuating circumstance not evident from the documentation listed below, a narrative and any available corroborating diagnostics must be submitted. As part of the re-review process Delta Dental may require documentation (e.g. photographs) in addition to that listed in this chart.

All radiographs are pretreatment unless otherwise indicated. Any radiograph submitted must be of diagnostic quality and substantiate the need and appropriateness of the service submitted for predetermination or payment. In order to do so, the dentist may need to submit radiographs in addition to those listed in this chart.

All procedures listed in this chart are not necessarily covered benefits, and all benefits are not necessarily listed.

Unless otherwise noted:

Yes = Documentation Required
Blank = Documentation Not Required
PA = Periapical Radiograph (may require more than one for diagnostic purposes)
FMX = Full Mouth Series
Pano = Panorex
DDNJ = Delta Dental of New Jersey

PLEASE NOTE: IF A MEDICAL EOB IS REQUIRED FOR AN ORAL SURGERY PROCEDURE ON A CLAIM, A MEDICAL EOB IS ALSO REQUIRED FOR RELATED EXAMS, X-RAYS AND ANESTHESIA.

ADA CDT-2007	Description	X-ray(s)	Perio Chart	Med EOB	Other
D0160	Detailed and extensive oral evaluation - problem focused, by report				Narrative
D0415	Collection of microorganisms for culture and sensitivity				Lab report of test performed
D0425	Caries susceptibility tests				Lab report of test performed
D0472-D0502	Oral pathology laboratory				Pathology report
D0999	Unspecified diagnostic procedure, by report				Narrative
D2335	Resin-based composite-four or more surfaces or involving incisal angle (anterior)	PA
D2390	Resin-based composite crown, anterior	PA
D2510-D2794	Inlays, onlays and crowns	PA
D2799	Provisional crown	PA			Narrative
D2950	Core buildup, including any pins	PA
D2952-D2953	Cast post and core in addition to crown and each additional cast post - same tooth	PA
D2954 & D2957	Prefabricated post and core in addition to crown and each additional prefabricated post - same tooth	PA
D2960-D2962	Labial veneers	PA
D2975	Coping	PA
D2980	Crown repair, by report				Narrative
D2999	Unspecified restorative procedure, by report				Narrative
D3110	Pulp cap - direct (excluding final restoration)	PA
D3331	Treatment of root canal obstruction; non-surgical access				Narrative
D3332	Incomplete endodontic therapy; inoperable or fractured tooth				Narrative
D3333	Internal root repair of perforation defects				Narrative
D3346	Retreatment of previous root canal therapy - anterior	PA both pre- and post-operative x-rays
D3347	Retreatment of previous root canal therapy - bicuspid	PA both pre- and post-operative x-rays
D3348	Retreatment of previous root canal therapy - molar	PA both pre- and post-operative x-rays
D3999	Unspecified endodontic procedure, by report				Narrative
D4210	Gingivectomy or gingivoplasty - four or more continguous teeth or bounded teeth spaces per quadrant		Yes		Narrative if more than 2 quadrants performed on same day
D4211	Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant		Yes		Narrative if more than 2 quadrants performed on same day
D4240	Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant		Yes		Narrative if implants are being performed. Narrative if more than 2 quadrants performed on same day
D4241	Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant		Yes		Narrative if implants are being performed. Narrative if more than 2 quadrants performed on same day
D4245	Apically positioned flap		Yes		Narrative if implants are being performed. Narrative if more than 2 quadrants performed on same day
D4249	Clinical crown lengthening - hard tissue	PA			Narrative
D4260	Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant	PA and/or FMX	Yes		Narrative if more than 2 quadrants performed on same day
D4261	Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant	PA and/or FMX	Yes		Narrative if more than 2 quadrants performed on same day
D4263-D4264	Bone replacement grafts	PA	Yes
D4265	Biologic materials to aid in soft and osseous tissue regeneration	PA	Yes		Narrative including type of material used
D4266-D4267	Guided tissue regeneration - per site	PA	Yes
D4268	Surgical revision procedure, per tooth	PA	Yes		Narrative
D4270-D4273	Soft tissue graft procedures		Yes		Narrative description of condition specify amount of attached gingiva
D4274	Distal or proximal wedge procedure		Yes
D4275	Soft tissue allograft		Yes		Narrative description of condition specify amount of attached gingiva
D4276	Combined connective tissue and double pedicle graft, per tooth		Yes		Narrative description of condition specify amount of attached gingiva
D4320-D4321	Provisional splinting	PA	Yes
D4341	Periodontal scaling and root planing - four or more teeth per quadrant		Yes		Narrative if more than 2 quadrants performed on same day
D4342	Periodontal scaling and root planing - one to three teeth, per quadrant		Yes
D4381	Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report	PA DDNJ requirement	Yes		Narrative including type of material used
D4910	Periodontal maintenance procedures		Yes, if third prophy
D4999	Unspecified periodontal procedure, by report				Narrative
D5820-D5821	Interim partial dentures				Narrative
D5860	Overdenture - complete, by report				Narrative
D5861	Overdenture - partial, by report				Narrative
D5862	Precision attachment, by report				Narrative
D5899	Unspecified removable prosthodontic procedure, by report				Narrative
D5999	Unspecified maxillofacial prosthesis by report				Narrative
D6010-D6050	Implant services	PA, and/or FMX, and/or Pano			6010 PA 6020 PA not required 6040 Pano 6050 Pano
D6053-D6079	Implant supported prosthetics	PA, and/or FMX, and/or Pano
D6080-D6090	Other implant services				Narrative
D6094	Implant supported prosthetics	PA, and/or FMX, and/or Pano
D6095-D6190	Other implant services				Narrative
D6194	Implant supported prosthetics	PA, and/or FMX, and/or Pano
D6199	Other implant services				Narrative
D6205-D6252	Fixed partial denture pontics	PA, and/or FMX, and/or Pano			Identify all missing teeth in both arches. Use tooth chart if available on claim form.
D6253	Provisional pontic	PA, and/or FMX, and/or Pano			Identify all missing teeth in both arches. Use tooth chart if available on claim form and narrative.
D6545-D6792	Fixed partial denture retainers - inlays/onlays and crowns. PA not required for D6548	PA, and/or FMX, and/or Pano			Identify all missing teeth in both arches. Use tooth chart if available on claim form.
D6793	Provisional retainer crown	PA, and/or FMX, and/or Pano			Identify all missing teeth in both arches. Use tooth chart if available on claim form and narrative.
D6794	Titanium crown	PA, and/or FMX, and/or Pano			Identify all missing teeth in both arches. Use tooth chart if available on claim form.
D6970-D6972	Cast/prefabricated post and cores	PA
D6973	Core build up for retainer, including any pins	PA
D6976-D6977	Each additional cast or prefabricated post - same tooth	PA
D6980	Fixed partial denture repair, by report				Narrative
D6999	Unspecified, fixed prosthodontic procedure, by report				Narrative
D7210	Surgical removal of erupted tooth requiring elevation of a mucoperiosteal flap and removal of bone and/or section of tooth	PA and/or Pano
D7220	Removal of impacted tooth - soft tissue	PA and/or Pano
D7230	Removal of impacted tooth - partially bony	PA and/or Pano		Yes
D7240	Removal of impacted tooth - completely bony	PA and/or Pano		Yes
D7241	Removal of impacted tooth - completely bony, with unusual surgical complications	PA and/or Pano		Yes	Narrative
D7250	Surgical removal of residual tooth roots (cutting procedure)	PA and/or Pano
D7260	Oroantral fistula closure			Yes
D7261	Primary closure of a sinus perforation	PA		Yes	Narrative
D7270	Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth	PA and/or Pano		Yes
D7272	Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)	PA and/or Pano
D7280	Surgical access of an unerupted tooth	PA
D7282	Mobilization of erupted or malpositioned tooth to aid eruption	PA
D7283	Placement of device to facilitate eruption of impacted tooth	PA
D7285-D7286	Biopsy of oral tissue			Yes	Pathology report
D7287	Exfoliative cytological sample collection			Yes	Narrative and pathology report
D7288	Brush biopsy - transepithelial sample collection
D7290	Surgical repositioning of teeth				Narrative
D7291	Transseptal fiberotomy/supra crestal fiberotomy, by report				Narrative
D7340	Vestibuloplasty - ridge extension (secondary epithelialization)				Narrative
D7350	Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)			Yes	Operative report
D7410-D7461	Surgical excision of soft tissue and intraosseous lesions			Yes	Pathology report
D7465	Destruction of lesion(s) by physical or chemical method, by report			Yes	Narrative
D7490	Radical resection of maxilla or mandible			Yes	Operative report
D7510-D7511	Incision and drainage of abscess				Narrative
D7520-D7521	Incision and drainage of abscess			Yes	Narrative
D7530	Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue			Yes	Operative report
D7540	Removal of reaction-producing foreign bodies, musculoskeletal system				Operative report
D7550	Partial ostectomy/sequestrectomy for removal of non-vital bone			Yes	Operative report
D7560	Maxillary sinusotomy for removal of tooth fragment or foreign body			Yes	Operative report
D7610-D7680	Treatment of fractures - simple			Yes	Operative report
D7710-D7780	Treatment of fractures - compound			Yes	Operative report
D7810-D7899	Reduction of dislocation and management of other TMJ dysfunctions			Yes	Operative report
D7910	Suture of recent small wounds up to 5 cm			Yes	Narrative
D7911-D7912	Complicated suturing			Yes	Narrative
D7920-D7950	Other repair procedures			Yes	Narrative
D7953	Bone replacement graft for ridge preservation - per site	PA			Narrative
D7955	Repair of maxillofacial soft and/or hard tissue defect			Yes	Narrative
D7970	Excision of hyperplastic tissue - per arch				Narrative
D7971	Excision of pericoronal gingiva				Narrative
D7980-D7999	Other repair procedures			Yes	Narrative
D8010-D8040	Limited orthodontic treatment				The following information must be provided on the claim form or via narrative: treatment time, total case fee, initial fee, retention fee.
D8050-D8060	Interceptive orthodontic treatment
D8070-8090	Comprehensive orthodontic treatment				Use narrative to notify DDNJ if treatment is longer or shorter than anticipated.
D8210-D8220	Minor treatment to control harmful habits
D8660	Pre-orthodontic treatment visit
D8670	Periodic orthodontic treatment visit (as part of contract)
D8680	Orthodontic retention (removal of appliances, construction and placement of retainer(s))
D8690	Orthodontic treatment (alternative billing to a contract fee)
D8691	Repair of orthodontic appliance				Narrative
D8692	Replacement of lost or broken retainer				Narrative
D8999	Unspecified orthodontic procedure, by report				Narrative
D9110	Palliative (emergency) treatment of dental pain - minor procedure				Narrative
D9120	Fixed partial denture sectioning	PA
D9220-D9221	Deep sedation/general anesthesia				Narrative if > 1 hour start/stop
D9241-D9242	Intravenous conscious sedation/analgesia				Narrative if > 1 hour start/stop
D9450	Case presentation, detailed and extensive treatment planning				Narrative
D9610	Therapeutic drug injection, by report				Narrative
D9630	Other drugs and/or medicaments, by report				Narrative
D9920	Behavior management, by report				Narrative
D9930	Treatment of complications (post-surgical) - unusual circumstances, by report