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

ADA CDT-2005	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