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
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 prosthetics by report				Narrative