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
D3110	Pulp cap - direct (excluding final restoration)	PA
D3331	Treatment of root canal obstruction; non-surgical access				Narrative
D3332	Incomplete endodontic therapy; inoperable, unrestorable 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