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 these charts.
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 these charts.
All procedures listed on these charts
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
DDPNJ = Delta Dental of New Jersey
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