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 this chart.

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 this chart.

Radiographic Submission Requirements
Whenever a participating dentist submits a claim that includes any combination of intraoral films whose combined fee equals or is greater than a complete series (D0210), the fee allowed will be limited to that of a complete series. Also, a panoramic film submitted together with supplemental radiographs will be handled in the same manner.

If a participating or non-participating dentist submits eight or more intraoral films and/or a panoramic radiograph with supplemental bitewings or periapical films, the dentist must submit a brief narrative as to the reason for taking the radiograph and also identify the tooth numbers of the periapical films if the radiographs are not part of a complete series or are not intended to function as a complete series. Delta Dental will consider that supplemental information in determining whether the x-rays will be subject to the limitations for individual x-rays rather than for a complete series.

All procedures listed in this chart 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
DDNJ = Delta Dental of New Jersey

Medical EOB Requirements
Medical plans may cover some dental procedures, such as oral surgery. This chart indicates if a procedure requires a medical EOB for processing. 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. 

Some groups have elected Delta Dental as the primary plan for oral surgery. A list of these groups is available on the Delta Dental of New Jersey website and is updated on a regular basis. A medical EOB is not required for the groups on this list. 

ADA CDT 2011/2012	Description	X-ray(s)	Perio Chart	Med EOB	Other
D0140	Limited oral evaluation - problem focused			Yes, if in conjunction with another procedure that requires a Med EOB	Narrative if within 21 days of surgical procedure and office records (on appeal)
D0160	Detailed and extensive oral evaluation - problem focused, by report			Yes, if in conjunction with another procedure that requires a Med EOB	Narrative if within 21 days of surgical procedure and office records (on appeal)
D0170	Re-evaluation - limited, problem focused (established patient; not post-operative visit)			Yes, if in conjunction with another procedure that requires a Med EOB	Narrative if within 21 days of surgical procedure and office records (on appeal)
D0220-D0277	Intraoral films - 8 or more PAs with or without any other intraoral films of any type			Yes, if in conjunction with another procedure that requires a Med EOB	If not a part of or intended to function as a complete series, submit with tooth numbers for each film and diagnostic purpose for taking the various films
D0330 + D0220-D0277	Panoramic films + intraoral films of any type			Yes, if in conjunction with another procedure that requires a Med EOB	If not a part of or intended to function as a complete series, submit with tooth numbers for each film and diagnostic purpose for taking the various films
D0415-D0431	Tests and examinations			Yes	Lab report of test performed
D0472-D0502	Oral pathology laboratory			Yes	Pathology report
D0999	Unspecified diagnostic procedure, by report				Narrative
D2335	Resin-based composite - four or more surfaces or involving incisal angle (anterior)	PA
D2390	Resin-based composite crown, anterior	PA
D2510-D2794	Inlays, onlays and crowns	PA			Photographs (optional)
D2799	Provisional crown	PA			Narrative
D2931-D2933	Stainless steel crown Prefabricated resin crown	PA if permanent tooth
D2950	Core buildup, including any pins	PA
D2952-D2953	Cast post and core in addition to crown and each additional cast post - same tooth	PA
D2954 & D2957	Prefabricated post and core in addition to crown and each additional prefabricated post - same tooth	PA
D2960-D2962	Labial veneers	PA			Pre-operative photos as necessary
D2970	Temporary crown (fractured tooth)	PA DDNJ requirement			Narrative
D2971	Additional procedures to construct new crown under existing partial denture framework				Narrative
D2975	Coping	PA
D2980	Crown repair, by report				Narrative
D2999	Unspecified restorative procedure, by report				Narrative
D3110	Pulp cap - direct (excluding final restoration)	PA			Operative notes (on appeal)
D3220	Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament				Narrative (if permanent tooth)
D3222	Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development	PA
D3230	Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)	PA
D3240	Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)	PA
D3331	Treatment of root canal obstruction; non-surgical access	PA			Narrative
D3332	Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth				Narrative
D3333	Internal root repair of perforation defects	PA			Narrative
D3346	Retreatment of previous root canal therapy - anterior	PA both pre- and post-operative x-rays
D3347	Retreatment of previous root canal therapy - bicuspid	PA both pre- and post-operative x-rays
D3348	Retreatment of previous root canal therapy - molar	PA both pre- and post-operative x-rays
D3351	Apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)				Narrative indicating if pulpal regeneration
D3352	Apexification/recalcification/pulpal regeneration - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)				Narrative indicating if pulpal regeneration
D3999	Unspecified endodontic procedure, by report				Narrative
D4210	Gingivectomy or gingivoplasty - four or more continguous teeth or tooth bounded spaces per quadrant		Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480) Toms River BOE (#07166)	Narrative if more than 2 quadrants performed on same day. Indicate if it is or is not being used for implant
D4211	Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant		Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480) Toms River BOE (#07166)	Narrative if more than 2 quadrants performed on same day. Indicate if it is or is not being used for implant
D4230	Anatomical crown exposure - four or more contiguous teeth per quadrant	PA			Narrative
D4231	Anatomical crown exposure - one to three teeth per quadrant	PA			Narrative
D4240	Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant		Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480)	Narrative if more than two quadrants performed on same day. Indicate if it is or is not being used for implant
D4241	Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant		Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480)	Narrative if more than two quadrants performed on same day. Indicate if it is or is not being used for implant
D4245	Apically positioned flap		Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480)	Narrative if implants are being performed.
D4249	Clinical crown lengthening - hard tissue	PA
D4260	Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant	PA and/or FMX	Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480)	Narrative if more than 2 quadrants performed on same day
D4261	Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant	PA and/or FMX	Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480)	Narrative if more than 2 quadrants performed on same day
D4263-D4264	Bone replacement grafts	PA	Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480)	Narrative which must indicate if it is or is not being used for implants
D4265	Biologic materials to aid in soft and osseous tissue regeneration	PA	Yes	Yes, if in conjunction with D7955 ALSO - Yes, when not in conjunction with implants for the following groups ONLY: Northeast Utlities (#05480)	Narrative which must indicate if it is or is not being used for implants and include type of material used
D4266-D4267	Guided tissue regeneration - per site	PA	Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480)	Narrative which must indicate if it is or is not being used for implants
D4268	Surgical revision procedure, per tooth	PA	Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480)	Narrative which must indicate if it is or is not being used for implants
D4270-D4271	Soft tissue graft procedures		Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480)	Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants
D4273	Soft tissue graft procedures		Yes		Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants
D4274	Distal or proximal wedge procedure		Yes	Yes, for the following groups ONLY: Northeast Utlities (#05480)
D4275	Soft tissue allograft		Yes		Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants
D4276	Combined connective tissue and double pedicle graft, per tooth		Yes		Narrative description of condition; specify amount of attached gingiva, and indicate if it is or is not being used for implants
D4320-D4321	Provisional splinting	PA	Yes
D4341	Periodontal scaling and root planing - four or more teeth per quadrant		Yes		Narrative if more than 2 quadrants performed on same day
D4342	Periodontal scaling and root planing - one to three teeth, per quadrant		Yes		Narrative if more than 2 quadrants performed on same day
D4381	Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report	PA DDNJ requirement	Yes, post scaling and root planing and prior to D4381 placement
D4910	Periodontal maintenance procedures		Yes, if third prophy
D4999	Unspecified periodontal procedure, by report				Narrative
D5810-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 prosthesis by report				Narrative
D6010-D6050	Implant services	PA, and/or FMX, and/or Pano			6010 PA 6040 Pano 6050 Pano
D6053-D6079, D6094, D6194	Implant supported prosthetics	PA, and/or FMX, and/or Pano			PAs must show adjacent teeth
D6080, D6090-D6095, D6100, D6190, D6199	Other implant services				Narrative
D6205-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
D6254	Interim 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, D6794	Fixed partial denture retainers - inlays/onlays and crowns.	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
D6795	Interim 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
D6975	Coping	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
D7210	Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated	PA and/or Pano		Yes, for the following groups ONLY: Hartford Hospital (#04590)
D7220	Removal of impacted tooth - soft tissue	PA and/or Pano		Yes, for the following groups ONLY: Capital Health (#03121) Hartford Hospital (#04590)
D7230	Removal of impacted tooth - partially bony	PA and/or Pano		Yes
D7240	Removal of impacted tooth - completely bony	PA and/or Pano		Yes
D7241	Removal of impacted tooth - completely bony, with unusual surgical complications	PA and/or Pano		Yes	Narrative
D7250	Surgical removal of residual tooth roots (cutting procedure)	PA and/or Pano		Yes, for the following groups ONLY: Hartford Hospital (#04590)	Narrative
D7251	Coronectomy - intentional partial tooth removal	PA and/or Pano			Narrative and operative report
D7260	Oroantral fistula closure			Yes	Narrative
D7261	Primary closure of a sinus perforation	PA		Yes
D7270	Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth	PA and/or Pano		Yes
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
D7282	Mobilization of erupted or malpositioned tooth to aid eruption	PA
D7283	Placement of device to facilitate eruption of impacted tooth	PA
D7285-D7286	Biopsy of oral tissue			Yes	Pathology report
D7287	Cytology sample collection			Yes	Narrative and pathology report
D7288	Brush biopsy - transepithelial sample collection				Narrative and pathology report
D7290	Surgical repositioning of teeth	PA
D7291	Transseptal fiberotomy/supra crestal fiberotomy, by report				Narrative
D7295	Harvest of bone for use in autogenuous grafting procedures	PA and/or Pano			Narrative and operative report
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)			Yes	Operative report and narrative (if PTE)
D7410-D7461	Surgical excision of soft tissue and intraosseous lesions			Yes	Pathology report
D7465	Destruction of lesion(s) by physical or chemical method, by report			Yes	Narrative
D7490	Radical resection of mandible with bone graft			Yes	Operative report including pathology report and narrative (if PTE)
D7510-D7511	Incision and drainage of abscess Intraoral - soft tissue				Narrative
D7520-D7521	Incision and drainage of abscess Extraoral - soft tissue			Yes	Narrative
D7530	Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue			Yes	Operative report and narrative (if PTE)
D7540	Removal of reaction-producing foreign bodies, musculoskeletal system				Operative report and narrative (if PTE)
D7550	Partial ostectomy/sequestrectomy for removal of non-vital bone			Yes	Operative report and narrative (if PTE)
D7560	Maxillary sinusotomy for removal of tooth fragment or foreign body			Yes	Operative report and narrative (if PTE)
D7610-D7680	Treatment of fractures - simple			Yes	Operative report and narrative (if PTE)
D7710-D7780	Treatment of fractures - compound			Yes	Operative report and narrative (if PTE)
D7810-D7877	Reduction of dislocation and management of other TMD dysfunctions			Yes	Operative report and narrative (if PTE)
D7880	Occlusal orthotic device				Narrative
D7899	Unspecified TMD therapy			Yes, if a surgical procedure	Narrative
D7910	Suture of recent small wounds up to 5 cm			Yes	Narrative
D7911-D7912	Complicated suturing			Yes	Narrative
D7920-D7949	Other repair procedures			Yes	Narrative
D7950	Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous	PA		Yes	Narrative indicating if the procedure is or is not being done in conjunction with implants
D7951	Sinus augmentation with bone or bone substitutes	PA			Narrative indicating if the procedure is or is not being done in conjunction with implants
D7953	Bone replacement graft for ridge preservation	PA			Narrative indicating if the procedure is or is not being done in conjunction with implants
D7955	Repair of maxillofacial soft and/or hard tissue defect	PA		Yes	Narrative indicating if the procedure is or is not being done in conjunction with implants
D7970	Excision of hyperplastic tissue - per arch		Yes, if natural teeth and/or implants are involved in surgery		Narrative
D7971	Excision of pericoronal gingiva				Narrative
D7980-D7999	Other repair procedures			Yes	Narrative
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 DDNJ if treatment is longer or shorter than anticipated.
D8050-D8060	Interceptive orthodontic treatment
D8070-8090	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
D8693	Rebonding or recementing; and/or repair, as required, of fixed retainers				Narrative
D8999	Unspecified orthodontic procedure, by report				Narrative
D9110	Palliative (emergency) treatment of dental pain - minor procedure				Narrative
D9120	Fixed partial denture sectioning	PA			Narrative
D9220-D9221	Deep sedation/general anesthesia			Yes, if in conjunction with another procedure that requires a Med EOB	Narrative and anesthesia record if > 1 hour start time/stop time
D9241-D9242	Intravenous conscious sedation/analgesia			Yes, if in conjunction with another procedure that requires a Med EOB	Narrative and anesthesia record if > 1 hour start time/stop time
D9310	Consultation			Yes, if in conjunction with another procedure that requires a Med EOB
D9450	Case presentation, detailed and extensive treatment planning				Narrative
D9610	Therapeutic parenteral drug, single administration				Narrative
D9612	Therapeutic parenteral drugs, two or more administrations, different medications				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			Yes, if in conjunction with another procedure that requires a Med EOB	Narrative
D9940	Occlusal guard, by report				Narrative
D9952	Occlusal adjustment - complete				Narrative
D9999	Unspecified adjunctive procedure, by report				Narrative