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
D9110	Palliative (emergency) treatment of dental pain - minor procedure			Narrative
D9220-D9221	Deep sedation/general anesthesia			Narrative if > 1 hour start/stop
D9241-D9242	Intravenous conscious sedation/analgesia			Narrative if > 1 hour start/stop
D9450	Case presentation, detailed and extensive treatment planning			Narrative
D9610	Therapeutic drug injection, by report			Narrative
D9630	Other drugs and/or medicaments, by report			Narrative
D9920	Behavior management, by report			Narrative
D9930	Treatment of complications (post-surgical) - unusual circumstances, by report			Narrative
D9940	Occlusal guard, by report			Narrative
D9952	Occlusal adjustment - complete			Narrative
D9999	Unspecified adjunctive procedure, by report			Narrative