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

PLEASE NOTE: IF A MEDICAL EOB IS REQUIRED FOR AN ORAL SURGERY PROCEDURE ON A CLAIM, A MEDICAL EOB IS ALSO REQUIRED FOR RELATED EXAMS, X-RAYS AND ANESTHESIA.

ADA CDT-4	Description	X-ray(s)	Perio Chart	Other
D7210	Surgical removal of erupted tooth requiring elevation of a mucoperiosteal flap and removal of bone and/or section of tooth	PA and/or Pano
D7220	Removal of impacted tooth - soft tissue	PA and/or Pano
D7230	Removal of impacted tooth - partially bony	PA and/or Pano
D7240	Removal of impacted tooth - completely bony	PA and/or Pano
D7241	Removal of impacted tooth - completely bony, with unusual surgical complications	PA and/or Pano		Narrative
D7250	Surgical removal of residual tooth roots (cutting procedure)	PA and/or Pano
D7261	Primary closure of a sinus perforation	PA		Narrative
D7270	Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth	PA and/or Pano
D7272	Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)	PA and/or Pano
D7280	Surgical access of an unerupted tooth	PA
D7281	Surgical exposure of impacted or unerupted tooth to aid eruption	PA
D7282	Mobilization of erupted or malpositioned tooth to aid eruption	PA
D7285-D7286	Biopsy of oral tissue			Pathology report
D7287	Cytology sample collection			Narrative and pathology report
D7290	Surgical repositioning of teeth			Narrative
D7291	Transseptal fiberotomy/supra crestal fiberotomy, by report			Narrative
D7340	Vestibuloplasty - ridge extension (secondary epithelialization)			Narrative
D7350	Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)			Operative report
D7410-D7461	Surgical excision of soft tissue and intra-osseous lesions			Pathology report
D7465	Destruction of lesions(s) by physical or chemical method, by report			Narrative
D7490	Radical resection of mandible with bone graft			Operative report
D7510-D7520	Incision and drainage of abscess			Narrative
D7530	Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue			Operative report
D7540	Removal of reaction-producing foreign bodies, musculoskeletal system			Operative report
D7550	Partial ostectomy/sequestrectomy for removal of non-vital bone			Operative report
D7560	Maxillary sinusotomy for removal of tooth fragment of foreign body			Operative report
D7610-D7680	Treatment of fractures - simple			Operative report
D7710-D7780	Treatment of fractures - compound			Operative report
D7810-D7899	Reduction of dislocation and management of other TMJ dysfunctions			Operative report
D7910	Suture of recent small wounds up to 5 cm			Narrative
D7911-D7912	Complicated suturing			Narrative
D7920-D7955	Other repair procedures			Narrative
D7970	Excision of hyperplastic tissue - per arch			Narrative
D7971	Excision of pericoronal gingiva			Narrative
D7980-D7999	Other repair procedures			Narrative