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
D8010-D8040	Limited orthodontic treatment			The following information must be provided on the claim form or via narrative: treatment time, total case fee, initial fee, retention fee. Use narrative to notify DDPNJ if treatment is longer or shorter than anticipated.
D8050-D8060	Interceptive orthodontic treatment
D8070-D8090	Comprehensive orthodontic treatment
D8210-D8220	Minor treatment to control harmful habits
D8660	Pre-orthodontic treatment visit
D8670	Periodic orthodontic treatment visit (as part of contract)
D8680	Orthodontic retention (removal of appliances, construction and placement of retainer(s))
D8690	Orthodontic treatment (alternative billing to a contract fee)
D8691	Repair of orthodontic appliance			Narrative
D8692	Replacement of lost or broken retainer			Narrative
D8999	Unspecified orthodontic procedure, by report			Narrative