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 Plan of New Jersey

ADA CDT-4	Description	X-ray(s)	Perio Chart	Other
D6010-D6050	Implant services	PA, and/or FMX, and/or Pano		D6010 PA D6020 PA not required D6040 Pano D6050 Pano
D6053-D6079	Implant supported prosthetics	PA, and/or FMX, and/or Pano
D6080-D6199	Other implant services			Narrative
D6210-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
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