XIAtAhi-CA-ENT-23 1
Attachment A
Deductibles, Maximums, Policy Benefit Levels and Enrollee Coinsurances
Summary of Benefits and Coverage
Family Dental Plan
Coinsurance Plan
Member Cost Share amounts describe the
Enrollee's out of pocket costs.
Pediatric Dental
Essential Health Benefits
Adult Dental
Up to Age 19
Age 19 and Older
Actuarial Value
85.44% 85.44%
Not Calculated
Not Calculated
In-Network:
Delta Dental
PPO
1
Out-of-
Network: Non-
Delta Dental
PPO
1
In-Network:
Delta Dental
PPO
1
Out-of-
Network: Non-
Delta Dental
PPO
1
Individual Deductible each Calendar Year
2,3
$75
$75
$50
$50
Family Deductible each Calendar Year (Two or
more children)
3
$150 $150
Not Applicable Not Applicable
Individual Out of Pocket Maximum each Calendar
Year
4
$350
None
Not Applicable
Not Applicable
Family Out of Pocket Maximum each Calendar
Year (Two or More Children)
4
$700 None
Not Applicable Not Applicable
Office Copay
$0
$0
$0
$0
Waiting Period
(Waivered Condition provision, as defined in
Health & Safety Code 1357.50 (a)(3)(J)(4) and
Insurance Code 10198.6(d)
None
None
Major Services
limited to
enrollees who
have been
enrolled in the
Policy for 6
consecutive
months, waived
with proof of prior
coverage
5
Major Services
limited to
enrollees who
have been
enrolled in the
Policy for 6
consecutive
months, waived
with proof of prior
coverage
5
Annual Benefit Limit
(the maximum amount the dental plan will pay in
the Calendar Year)
None
None
$1,500
Procedure
Category
Service Type
Member Cost
Share
6
Member Cost
Share
6
Member Cost
Share
6
Member Cost
Share
6
Oral Exam
No charge
10%
No charge
10%
XIAtAhi-CA-ENT-23 2
Diagnostic &
Preventive
Preventive - Cleaning
No charge
10%
No charge
10%
Preventive - X-ray
No charge
10%
No charge
10%
Sealants per Tooth
No charge
10%
Not Covered
Not Covered
Topical Fluoride Application
No charge
10%
Not Covered
Not Covered
Space Maintainers - Fixed
No charge
10%
Not Covered
Not Covered
Basic Services
Restorative Procedures
20%
Deductible
Applies
30%
Deductible
Applies
20%
Deductible
Applies
30%
Deductible
Applies
Periodontal
Maintenance Services
Major Services
Periodontics (other
than maintenance)
50%
Deductible
Applies
50%
Deductible
Applies
50%
Deductible
Applies
50%
Deductible
Applies
Endodontics
Crowns and Casts
Prosthodontics
Oral Surgery
Orthodontia
Medically Necessary
Orthodontia
7
50%
Deductible
Applies
50%
Deductible
Applies
Not Covered
Not Covered
1
Reimbursement is based on Delta Dental PPO Contracted Fees for Delta Dental PPO, Delta Dental Premier
and Non-Delta Dental Providers.
2
Each adult is responsible for an individual Deductible. Adult Deductible is waived for Diagnostic and
Preventive Services.
3
In a coinsurance plan, each child is responsible for the individual Deductible unless the family Deductible has
been met. Once a child’s individual Deductible or the family Deductible is reached, cost sharing applies until
the child’s Out-of-Pocket Maximum is reached.
In a plan with two or more children, cost sharing payments made by each individual child for in-network
services contribute to the family in-network Deductible, if applicable, as well as the family Out-of-Pocket
Maximum.
In a plan with two or more children, cost sharing payments made by each individual child for out-of-network
covered services contribute to the family out-of-network Deductible, if applicable, and do not accumulate to
the family Out-of-Pocket Maximum.
Pediatric Deductible is waived for Diagnostic and Preventive Services.
4
Out-of-Pocket Maximum applies only to Essential Health Benefits that are provided by Delta Dental PPO
Providers for Pediatric Enrollees. Once the amount paid by Pediatric Enrollee(s) equals the Out-of-Pocket
Maximum, no further payment will be required by the Pediatric Enrollee(s) for the remainder of the
Calendar Year for covered services received from Delta Dental PPO Providers. Enrollee Coinsurance and
other cost sharing, including balance billed amounts, will continue to apply for covered services from Delta
Dental Premier or Non-Delta Dental PPO Providers even after the Out-of-Pocket Maximum is met.
XIAtAhi-CA-ENT-23 3
If two or more Pediatric Enrollees are covered, the financial obligation for covered services received from
Delta Dental PPO Providers is not more than the multiple Pediatric Enrollees Out-of-Pocket Maximum.
However, once a Pediatric Enrollee meets the Out-of-Pocket Maximum for one covered Pediatric Enrollee,
that Pediatric Enrollee will have satisfied their Out-of-Pocket Maximum. Other covered Pediatric Enrollees
must continue to pay Enrollee Coinsurance for covered services received from Delta Dental PPO Providers
until the total amount paid reaches the Out-of-Pocket Maximum for multiple Pediatric Enrollees.
5
The six month waiting period (Adult only) for major services must be waived upon a member’s provision of
proof of prior comparable dental coverage. This waiting period shall be prorated on a one to one monthly
basis upon a member’s provision of proof of prior comparable dental coverage of less than six months.
Covered California leaves it to the plan to determine acceptable documentation to verify prior proof of
coverage. Covered California leaves it to the plan to determine the maximum allowable gap in coverage
before proration of the six month waiting period would no longer occur. Dental services obtained via a
discount health plan are not considered “comparable” dental coverage for purposes of counting towards the
waiting period.
6
Delta Dental will pay or otherwise discharge the Policy Benefit Level according to the Maximum Contract
Allowance for covered services. Note: Policy Benefit Levels differ between Delta Dental PPO Providers and
Non-Delta Dental PPO Providers. The greatest benefits – including out-of-pocket savings – occur when
covered services are received by a Delta Dental PPO Provider. The amount charged to Enrollees for covered
services performed by a Non-Delta Dental PPO Provider may be above that accepted by Delta Dental PPO
Providers, and Enrollees will be responsible for balance billed amounts.
7
Member cost share for Medically Necessary Orthodontia services applies to course of treatment, not
individual benefit years within a multi-year course of treatment. This member cost share applies to the
course of treatment as long as the member remains enrolled in the plan.
XIAtBhi-CA-ENT-23 1
Attachment B
Services, Limitations and Exclusions
Description of Dental Services for Adult Benefits (age 19 and older)
Delta Dental will pay or otherwise discharge the Policy Benefit Level shown in Attachment A for the following
services:
• Diagnostic and Preventive Services
(1) Diagnostic:
procedures to aid the Provider in determining required dental treatment,
including x-rays and oral exams.
(2) Preventive:
cleaning, including scaling in presence of generalized moderate or severe
gingival inflammation – full mouth (periodontal maintenance is considered to
be a Basic Service for payment purposes).
(3) Specialist
Consultations:
opinion or advice requested by a general dentist.
• Basic Services
(1) General Anesthesia or
IV Sedation:
when administered by a Provider for covered Oral Surgery or selected
endodontic and periodontal surgical procedures.
(2) Periodontal Cleanings:
periodontal maintenance.
(3) Palliative:
emergency treatment to relieve pain.
(4) Restorative:
amalgam and resin-based composite restorations (fillings) and prefabricated
restorations for treatment of carious lesions (visible destruction of hard
tooth structure resulting from the process of decay).
• Major Services
(1) Crowns and
Inlays/Onlays:
treatment of carious lesions (visible decay of the hard tooth structure) when
teeth cannot be restored with amalgam or resin-based composites.
(2) Prosthodontics:
procedures for construction of fixed bridges, partial or complete dentures
and the repair of fixed bridges.
(3) Oral Surgery:
extractions and certain other surgical procedures (including pre-and post-
operative care).
(4) Endodontics:
treatment of diseases and injuries of the tooth pulp.
(5) Periodontics:
treatment of gums and bones supporting teeth.
(6) Denture Repairs:
repair to partial or complete dentures, including rebase procedures and
relining.
• Note on additional Benefits during pregnancy
When an Enrollee is pregnant, Delta Dental will pay for additional services to help improve the oral health of
the Enrollee during the pregnancy. The additional services each Calendar Year while the Enrollee is covered
under the Policy include one (1) additional oral exam and either one (1) additional routine cleaning; one (1)
additional periodontal scaling and root planing per quadrant; or one (1) additional periodontal maintenance
procedure. Written confirmation of the pregnancy must be provided by the Enrollee or her Provider when the
claim is submitted.
Limitations for Adult Benefits (age 19 and older)
(1) Services that are more expensive than the form of treatment customarily provided under accepted dental
practice standards are called “Optional Services.” Optional Services also include the use of specialized
techniques instead of standard procedures.
XIAtBhi-CA-ENT-23 2
Examples of Optional Services:
a) a composite restoration instead of an amalgam restoration on posterior teeth;
b) a crown where a filling would restore the tooth;
c) an inlay/onlay instead of an amalgam restoration; or
d) porcelain, resin or similar materials for crowns placed on a maxillary second or third molar, or on any
mandibular molar (an allowance will be made for a porcelain fused to high noble metal crown).
If an Enrollee receives Optional Services, an alternate Benefit will be allowed, which means Delta Dental
will base Benefits on the lower cost of the customary service or standard practice instead of on the higher
cost of the Optional Service.The Enrollee will be responsible for the difference between the higher cost of
the Optional Service and the lower cost of the customary service or standard procedure.
(2) Delta Dental will pay for oral examinations (except after hours exams and exams for observation) no more
than twice in a calendar year.
(3) Delta Dental will pay for cleanings, including scaling in presence of generalized moderate or severe
gingival inflammation (including periodontal maintenance or any combination thereof) no more than
twice in a Calendar Year. A full mouth debridement is allowed once in a lifetime when the Enrollee has no
history of prophylaxis, scaling and root planing, periodontal surgery, or periodontal maintenance
procedures within three years and counts toward the cleaning frequency in the year provided. Note that
periodontal maintenance, Procedure Codes that include periodontal maintenance, and full mouth
debridement are covered as a Basic Benefit, and routine cleanings including scaling in presence of
generalized moderate or severe gingival inflammation are covered as a Diagnostic and Preventive Benefit.
See note on additional Benefits during pregnancy.
(4) Full mouth debridement is not allowed when performed by the same dentist/dental office on the same
day as evaluation procedures.
(5) A caries risk assessment is allowed once in 12 months. An interim caries arresting medicament application
is covered once per tooth every six (6) months when Enrollee has a caries risk assessment and
documentation with a finding of high risk.
(6) X-ray limitations:
a) Delta Dental will limit the total reimbursable amount to the Provider’s Accepted Fee for a complete
intraoral series when the fees for any combination of intraoral x-rays in a single treatment series
meet or exceed the Accepted Fee for a complete intraoral series.
b) When a panoramic film is submitted with supplemental film(s), Delta Dental will limit the total
reimbursable amount to the Provider's Accepted Fee for a complete intraoral series.
c) If a panoramic film is taken in conjunction with an intraoral complete series, Delta Dental considers
the panoramic film to be included in the complete series
d) A complete intraoral series and panoramic film are each limited to once every 60 months.
e) Bitewing x-rays are limited to one (1) time each Calendar Year. Bitewings of any type are not billable
to the Enrollee or Delta Dental within 12 months of a full mouth series unless warranted by special
circumstances.
f) Image capture procedures are not separately allowable service.
(7) Pulp vitality tests are allowed once per day when definitive treatment is not performed.
(8) Specialist Consultations are limited to once per lifetime per Provider and count toward the oral exam
frequency. Screenings of patients or assessments of patients reported individually when covered, are
limited to only one in a 12-month period and included if reported, with any other examination on the
same date of service and Provider office.
(9) Delta Dental will not cover to replace amalgam and resin-based composite restorations (fillings) and
prefabricated restorations within 24 months of treatment if the service is provided by the same
Provider/Provider office. Replacement restorations, including reattachment of a tooth fragment, within
24 months are included in the fee for the original restoration.
(10) Protective restorations (sedative fillings) are allowed once per tooth per lifetime when definitive
treatment is not performed on the same date of service.
XIAtBhi-CA-ENT-23 3
(11) Therapeutic pulpotomy is limited to once per lifetime for baby (deciduous) teeth only and is considered
palliative treatment for permanent teeth.
(12) Pulpal debridement and partial pulpotomy for apexogenesis are limited to once per lifetime.
(13) Pulpal therapy (resorbable filling) is limited to once in a lifetime. Retreatment of root canal therapy by the
same Provider/Provider office within 24 months is considered part of the original procedure.
(14) Hemisection (including any root removal), not including root canal therapy, root amputation per root,
internal root repair of perforation defects and incomplete endodontic therapy; inoperable, unrestorable
or fractured tooth are limited to once in a lifetime.
(15) Retreatment of apical surgery by the same Provider/Provider office within 24 months is considered part of
the original procedure.
(16) Pin retention is covered not more than once in any 24-month period.
(17) Palliative treatment is covered per visit, not per tooth, and the fee includes all treatment provided other
than required x-rays or select Diagnostic procedures.
(18) Periodontal limitations:
a) Benefits for periodontal scaling and root planing in the same quadrant are limited to once in every
24-month period. See note on additional Benefits during pregnancy. In the absence of supporting
documentation, no more than two quadrants of scaling and root planing will be benefited on the
same date of service.
b) Periodontal surgery in the same quadrant is limited to once in every 36-month period and includes
any surgical re-entry or scaling and root planing performed within 36-months by the same
dentist/dental office.
c) Periodontal services, including bone replacement grafts, guided tissue regeneration, graft procedures
and biological materials to aid in soft and osseous tissue regeneration are only covered for the
treatment of natural teeth and are not covered when submitted in conjunction with extractions,
periradicular surgery, ridge augmentation or implants.
d) Guided tissue regeneration is not benefited in conjunction with soft tissue grafts in the same surgical
area.
e) Periodontal surgery is subject to a 30 day wait following periodontal scaling and root planing in the
same quadrant.
f) Cleanings (regular and periodontal) and full mouth debridement are subject to a 30 day wait
following periodontal scaling and root planing if performed by the same Provider office.
(19) Oral Surgery services are covered once in a lifetime except removal of benign odontogenic cysts or
tumors, excision of benign lesions and incision and drainage procedures, which are covered once in the
same day.
(20) General anesthesia, intravenous moderate (conscious) sedation is a benefit only when provided by a
dentist in conjunction with covered oral surgery procedures or selected endodontic and periodontal
surgical procedures.
(21) Crowns and Inlays/Onlays are covered not more often than once in any 60 month period except when
Delta Dental determines the existing Crown or Inlay/Onlay is not satisfactory and cannot be made
satisfactory because the tooth involved has experienced extensive loss or changes to tooth structure or
supporting tissues.
(22) Core buildup, including any pins, is covered not more than once in any 60 month period.
(23) Post and core services are covered not more than once in any 60 month period.
(24) Crown repairs are covered not more than once in any 60 month period. Crowns, inlays/onlays and fixed
bridges include repairs for twenty-four (24) months following installation.
(25) When allowed within six (6) months of a restoration, the Benefit for a Crown, Inlay/Onlay or fixed
prosthodontic service will be reduced by the Benefit paid for the restoration.
XIAtBhi-CA-ENT-23 4
(26) Denture Repairs are covered not more than once in any six (6) month period except for fixed Denture
Repairs which are covered not more than once in any 60 month period.
(27) Prosthodontic appliances that were provided under any Delta Dental program will be replaced only after
60 months have passed, except when Delta Dental determines that there is such extensive loss of
remaining teeth or change in supporting tissue that the existing fixed bridge or denture cannot be made
satisfactory. Replacement of a prosthodontic appliance is not provided under a Delta Dental program will
be made if Delta Dental determines it is unsatisfactory and cannot be made satisfactory.
(28) When a posterior fixed bridge and a removable partial denture are placed in the same arch in the same
treatment episode, only the partial denture will be a Benefit.
(29) Recementation of Crowns, Inlays/Onlays, indirectly fabricated or prefabricated post and core, or bridges is
included in the fee for the Crown, Inlay/Onlay or bridge when performed by the same Provider/Provider
office within six (6) months of the initial placement. After six (6) months, payment will be limited to one
(1) recementation in a lifetime by the same Provider/Provider office.
(30) The initial installation of a prosthodontic appliance is not a Benefit unless the prosthodontic appliance,
bridge or denture is made necessary by natural, permanent teeth extraction occurring during a time the
Enrollee was under a Delta Dental plan.
(31) Occlusal adjustment - limited, is allowed once in a 60-month period.
(32) Delta Dental limits payment for dentures to a standard partial or complete denture (Enrollee
Coinsurances apply). A standard denture means a removable appliance to replace missing natural,
permanent teeth that is made from acceptable materials by conventional means and includes routine
post delivery care including any adjustments and relines for the first six (6) months after placement.
a) Denture rebase is limited to one (1) per arch in a 24-month period and includes any relining and
adjustments for six (6) months following placement.
b) Dentures, removable partial dentures and relines include adjustments for six (6) months following
installation. After the initial six (6) months of an adjustment or reline, adjustments are limited to two
(2) per arch in a Calendar Year and relining is limited to one (1) per arch in a six (6) month period.
Immediate dentures, and immediate removable partial dentures include adjustments for three (3)
months following installation. After the initial three (3) months of an adjustment or reline,
adjustments are limited to two (2) per arch in a Calendar Year and relining is limited to one (1) per
arch in a six (6) month period.
c) Tissue conditioning is limited to two (2) per arch in a 12-month period. However, tissue conditioning
is not allowed as a separate Benefit when performed on the same day as a denture reline or rebase
service.
d) Recementation of fixed partial dentures is limited to once in a lifetime.
(33) Frenulectomy is only considered in cases of ankyloglossia (tongue-tie) interfering with feeding or speech
as diagnosed and documented by a physician, or if there is a papilla penetrating frenum interfering with
closure of a diastema.
(34) The fees for synchronous/asynchronous teledentistry services are considered inclusive in overall patient
management and are not separately payable service.
Exclusions for Adult Benefits (age 19 and older)
Delta Dental does not pay Benefits for:
(1) treatment of injuries or illness covered by workers' compensation or employers' liability laws; services
received without cost from any federal, state or local agency, unless this exclusion is prohibited by law.
(2) cosmetic surgery or procedures for purely cosmetic reasons, including teeth whitening and veneers.
(3) maxillofacial prosthetics.
(4) provisional and/or temporary restorations.
XIAtBhi-CA-ENT-23 5
(5) services for congenital (hereditary) or developmental (following birth) malformations, including but not
limited to cleft palate, upper and lower jaw malformations, enamel hypoplasia (lack of development),
fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), except those
services provided to newborn children for medically diagnosed congenital defects or birth abnormalities.
(6) treatment to stabilize teeth, treatment to restore tooth structure lost from wear, erosion, or abrasion or
treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion. Examples
include but are not limited to: equilibration, periodontal splinting, complete occlusal adjustments or Night
Guards/Occlusal guards and abfraction.
(7) any Single Procedure provided prior to the date the Enrollee became eligible for services under this plan.
(8) prescribed drugs, medication, pain killers, antimicrobial agents, or experimental/investigational
procedures.
(9) charges for anesthesia, other than General Anesthesia and IV Sedation administered by a Provider in
connection with covered Oral Surgery or selected endodontic and periodontal surgical procedures.
(10) extraoral grafts (grafting of tissues from outside the mouth to oral tissues).
(11) services for implants(prosthetic appliances placed into or on the bone of the upper or lower jaw to retain
or support dental prosthesis), their removal or other associated procedures.
(12) indirectly fabricated resin-based Inlays/Onlays.
(13) charges by any hospital or other surgical or treatment facility and any additional fees charged by the
Provider for treatment in any such facility.
(14) treatment by someone other than a Provider or a person who by law may work under a Provider’s direct
supervision.
(15) charges incurred for oral hygiene instruction, a plaque control program, preventive control programs
including home care times, dietary instruction, x-ray duplications, cancer screening, tobacco counseling or
broken appointments are not separately payable procedures.
(16) dental practice administrative services including, but not limited to, preparation of claims, any non-
treatment phase of dentistry such as provision of an antiseptic environment, sterilization of equipment or
infection control, or any ancillary materials used during the routine course of providing treatment such as
cotton swabs, gauze, bibs, masks or relaxation techniques such as music.
(17) procedures having a questionable prognosis based on a dental consultant’s professional review of the
submitted documentation.
(18) any tax imposed (or incurred) by a government, state or other entity, in connection with any fees charged
for Benefits provided under the Policy, will be the responsibility of the Enrollee and not a covered Benefit.
(19) Deductibles, amounts over plan maximums and/or any service not covered under the dental plan.
(20) services covered under the dental plan but exceed Benefit limitations or are not in accordance with
processing policies in effect at the time the claim is processed.
(21) the initial placement of any prosthodontic appliance, unless such placement is needed to replace one or
more natural, permanent teeth extracted while the Enrollee is covered under the Policy or was covered
under any dental care plan with Delta Dental.The extraction of a third molar (wisdom tooth) will not
qualify under the above. Any such denture or fixed bridge must include the replacement of the extracted
tooth or teeth.
(22) services for Orthodontic treatment (treatment of malocclusion of teeth and/or jaws) including
orthodontic related services such as cephalometric x-rays, oral/facial photographic images and diagnostic
casts, surgical access of an unerupted tooth, placement of device to facilitate eruption of impacted tooth
and surgical repositioning of teeth.
(23) services for any disturbance of the temporomandibular (jaw) joints (TMJ) or associated musculature,
nerves and other tissues.
XIAtBhi-CA-ENT-23 6
(24) services or supplies for sealants, fluoride, space maintainers, apexification and transseptal
fiberotomy/supra crestal fiberotomy.
(25) missed and/or cancelled appointments.
(26) actions taken to schedule and assure compliance with patient appointments are inclusive with office
operations and are not a separately payable service.
(27) the fees for care coordination are considered inclusive in overall patient management and are not a
separately payable service.
(28) dental case management motivational interviewing and patient education to improve oral health literacy.
(29) non-ionizing diagnostic procedure capable of quantifying, monitoring and recording changes in structure
of enamel, dentin, and cementum.
(30) extra-oral – 2D projection radiographic image and extra-oral posterior dental radiographic image.
(31) diabetes testing.
(32) corticotomy (specialized oral surgery procedures associated with orthodontics).
(33) Antigen or antibody testing.
(34) counseling for the control and prevention of adverse oral, behavioral, and systemic health effects
associated with high-risk substance use.
Description of Dental Services for Pediatric Benefits (under age 19)
Delta Dental will pay or otherwise discharge the Policy Benefit Level shown in Attachment A for Essential Health
Benefits and benefits listed below in the Schedule of Covered Services when provided by a Provider and when
necessary and customary under generally accepted dental practice standards and for medically necessary
Orthodontic Services. Orthodontic treatment is a benefit of this dental plan only when medically necessary as
evidenced by a severe handicapping malocclusion and when a prior authorization is obtained. Severe handicapping
malocclusion is not a cosmetic condition. Teeth must be severely misaligned causing functional problems that
compromise oral and/or general health. Benefits for medically necessary orthodontics will be provided in periodic
payments based on continued enrollment.
• Diagnostic and Preventive Services
(1) Diagnostic:
procedures to aid the Provider in determining required dental treatment,
including x-rays and oral exams.
(2) Preventive:
cleaning, including scaling in presence of generalized moderate or severe gingival
inflammation – full mouth (periodontal maintenance is considered to be a Basic
Benefit for payment purposes), topical application of fluoride solutions, space
maintainers.
(3) Sealants:
topically applied acrylic, plastic or composite materials used to seal
developmental grooves and pits in permanent molars for the purpose of
preventing decay.
(4) Specialist
Consultations:
opinion or advice requested by a general dentist.
• Basic Services
(1) General Anesthesia
or IV Sedation:
when administered by a Provider for covered Oral Surgery or selected
endodontic and periodontal surgical procedures.
(2) Periodontal
Cleanings:
periodontal maintenance.
(3) Palliative:
emergency treatment to relieve pain.
(4) Restorative:
amalgam and resin-based composite restorations (fillings) and prefabricated
stainless steel restorations for treatment of carious lesions (visible destruction
of hard tooth structure resulting from the process of decay).
XIAtBhi-CA-ENT-23 7
• Major Services
(1) Crowns:
treatment of carious lesions (visible decay of the hard tooth structure) when teeth
cannot be restored with amalgam or resin-based composites.
(2) Prosthodontics:
procedures for construction of partial or complete dentures and the repair of fixed
bridges; implant surgical placement and removal; and for implant supported
prosthetics, including implant repair and recementation.
(3) Oral Surgery:
extractions and certain other surgical procedures (including pre-and post-operative
care).
(4) Endodontics:
treatment of diseases and injuries of the tooth pulp.
(5) Periodontics:
treatment of gums and bones supporting teeth.
(6) Denture
Repairs:
repair to partial or complete dentures, including rebase procedures and relining.
• Note on Early Periodic Screening, Diagnosis and Treatment (EPSDT) Benefit.
Administration of this plan design must comply with requirements of the pediatric dental EHB benchmark
plan, including coverage of services in circumstances of medical necessity as defined in the Early Periodic
Screening, Diagnosis and Treatment (EPSDT) benefit.
• Note on additional Benefits during pregnancy
When an Enrollee is pregnant, Delta Dental will pay for additional services to help improve the oral health of
the Enrollee during the pregnancy. The additional services each Calendar Year while the Enrollee is covered
under the Policy include one (1) additional oral exam and either one (1) additional routine cleaning; one (1)
additional periodontal scaling and root planing per quadrant; or one (1) additional periodontal maintenance
procedure. Written confirmation of the pregnancy must be provided by the Enrollee or her Provider when the
claim is submitted.
Schedule of Covered Services
The Procedure Codes and nomenclature in this schedule are copyright of the American Dental Association. This table represents
Procedure Codes and nomenclature excerpted from the version of Current Dental Terminology (CDT®) in effect at the date of this
printing. Delta Dental’s administration of Benefits, limitations and exclusions under this Plan at all times will be based on the current
version of CDT whether or not a revised table is provided.
Procedure
Code
Procedure Description and Limitations
Diagnostic and Preventive Services
D0120
Periodic oral evaluation - established patient: once every 6 months per provider
D0140
Limited oral evaluation - problem focused: once per patient per provider
D0145
Oral evaluation for a patient under three years of age and counseling with primary caregiver
D0150
Comprehensive oral evaluation - new or established patient: once per patient per provider
D0160
Detailed and extensive oral evaluation - problem focused, by report: once per patient per provider
D0170
Re-evaluation - limited, problem focused (established patient; not post-operative visit): 6 in 3 months, not to
exceed 12 in 12 months
D0171
Re-evaluation - post-operative office visit
D0180
Comprehensive periodontal evaluation - new or established patient
D0210
Intraoral - complete series of radiographic images: once per provider every 36 months
D0220
Intraoral - periapical first radiographic image: maximum of 20 images (D0220, D0230) in 12 months per provider
D0230
Intraoral - periapical each additional radiographic image: maximum of 20 images (D0220, D0230) in 12 months per
provider
D0240
Intraoral - occlusal radiographic image: maximum of 2 in 6 months per provider
XIAtBhi-CA-ENT-23 8
D0250
Extra-oral – 2D projection radiographic image created using a stationary radiation source, and detector: once per
date of service
D0251
Extra-oral posterior dental radiographic image: 4 per date of service
D0270
Bitewing - single radiographic image: once per date of service
D0272
Bitewings - two radiographic images: once every 6 months per provider
D0273
Bitewings - three radiographic image
D0274
Bitewings - four radiographic images: once every 6 months per provider, age 10 and older
D0277
Vertical bitewings - 7 to 8 radiographic images: maximum of 4
D0310
Sialography
D0320
Temporomandibular joint arthrogram, including injection: maximum of 3 per date of service
D0322
Tomographic survey: twice in 12 months per provider
D0330
Panoramic radiographic image: once in 36 months per provider
D0340
2D cephalometric radiographic image – acquisition, measurement and analysis: twice in 12 months per provider
D0350
2D oral/facial photographic image obtained intra-orally or extra-orally: maximum of 4 per date of service
D0351
3D photographic image: once per date of service
D0460
Pulp vitality tests
D0470
Diagnostic casts: once per provider
D0502
Other oral pathology procedures, by report
D0601
Caries risk assessment and documentation, with a finding of low risk: one procedure (D0601, D0602, D0603) every
12 months per provider
D0602
Caries risk assessment and documentation, with a finding of moderate risk: one procedure (D0601, D0602, D0603)
every 12 months per provider
D0603
Caries risk assessment and documentation, with a finding of high risk: one procedure (D0601, D0602, D0603) every
12 months per provider
D0701
Panoramic radiographic image – image capture only
D0702
2-D cephalometric radiographic image – image capture only
D0703
2-D oral/facial photographic image obtained intra-orally or extra-orally –
image capture only
D0704
3-D photographic image – image capture only
D0705
Extra-oral posterior dental radiographic image – image capture only
D0706
Intraoral – occlusal radiographic image – image capture only
D0707
Intraoral – periapical radiographic image – image capture only
D0708
Intraoral – bitewing radiographic image – image capture only
D0709
Intraoral – complete series of radiographic images – image capture only
D0999
Unspecified diagnostic procedure, by report
D1110
Prophylaxis - adult: once every 6 months
D1120
Prophylaxis - child: once every 6 months
D1206
Topical application of fluoride varnish: once every 6 months and frequency limitation applies towards D1208
D1208
Topical application of fluoride – excluding varnish: once every 6 months and frequency limitation applies towards
D1206
D1310
Nutritional counseling for control of dental disease
D1320
Tobacco counseling for the control and prevention of oral disease
D1321
Counseling for the control and prevention of adverse oral, behavioral, and
systemic health effects associated with high-risk substance use
D1330
Oral hygiene instructions
XIAtBhi-CA-ENT-23 9
D1351
Sealant - per tooth: once per permanent molar every 36 months per provider if they are without caries (decay) or
restorations on the occlusal surface.
D1352
Preventive resin restoration in a moderate to high caries risk patient – permanent tooth: once per tooth every 36
months per provider
D1353
Sealant repair - per tooth
D1354
Interim caries arresting medicament application - per tooth: once every 6 months
D1355
Caries preventive medicament application – per tooth
D1510
Space maintainer - fixed - unilateral- per quadrant: once per quadrant per patient through age 17
D1516
Space maintainer - fixed – bilateral, maxillary: once per arch per patient through age 17
D1517
Space maintainer - fixed – bilateral, mandibular: once per arch per patient through age 17
D1520
Space maintainer - removable - unilateral- per quadrant: once per quadrant per patient through age 17
D1526
Space maintainer - removable – bilateral, maxillary: once per arch per patient through age 17
D1527
Space maintainer - removable – bilateral, mandibular: once per arch per patient through age 17
D1551
Re-cement or re-bond bilateral space maintainer – maxillary: once per provider per quadrant or arch through age
17
D1552
Re-cement or re-bond bilateral space maintainer - mandibular: once per provider per quadrant or arch through age
17
D1553
Re-cement or re-bond unilateral space maintainer - per quadrant: once per provider per quadrant or arch through
age 17
D1556
Removal of fixed unilateral space maintainer - per quadrant
D1557
Removal of fixed bilateral space maintainer - maxillary
D1558
Removal of fixed bilateral space maintainer - mandibular
D1575
Distal shoe space maintainer – fixed, unilateral- per quadrant: once per quadrant per lifetime; under age 9
D4346
Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation:
once every 6 months
D9310
Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician
D9311
Consultation with a medical health care professional
D9997
Dental case management - patients with special health care needs
Basic Services
D2140
Amalgam - one surface, primary or permanent: once in 12 months for primary teeth, once in 36 months for
permanent teeth
D2150
Amalgam - two surfaces, primary or permanent: once in 12 months for primary teeth, once in 36 months for
permanent teeth
D2160
Amalgam - three surfaces, primary or permanent: once in 12 months for primary teeth, once in 36 months for
permanent teeth
D2161
Amalgam - four or more surfaces, primary or permanent: once in 12 months for primary teeth, once in 36 months
for permanent teeth
D2330
Resin-based composite - one surface, anterior: once in 12 months for primary teeth, once in 36 months for
permanent teeth
D2331
Resin-based composite - two surfaces, anterior: once in 12 months for primary teeth, once in 36 months for
permanent teeth
D2332
Resin-based composite - three surfaces, anterior: once in 12 months for primary teeth, once in 36 months for
permanent teeth
D2335
Resin-based composite - four or more surfaces or involving incisal angle (anterior): once in 12 months for primary
teeth, once in 36 months for permanent teeth
D2390
Resin-based composite crown, anterior: once in 12 months for primary teeth , once in 36 months for permanent
teeth
D2391
Resin-based composite - one surface, posterior: once in 12 months for primary teeth, once in 36 months for
permanent teeth
XIAtBhi-CA-ENT-23 10
D2392
Resin-based composite - two surfaces, posterior: once in 12 months for primary teeth, once in 36 months for
permanent teeth
D2393
Resin-based composite - three surfaces, posterior: once in 12 months for primary teeth, once in 36 months for
permanent teeth
D2394
Resin-based composite - four or more surfaces, posterior: once in 12 months for primary teeth, once in 36 months
for permanent teeth
D2910
Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration: once in 12 months per provider
D2915
Re-cement or re-bond indirectly fabricated or prefabricated post and core: performed in conjunction with
recementation of existing or new crown and is not separately payable
D2920
Re-cement or re-bond crown
D2921
Reattachment of tooth fragment, incisal edge or cusp: once in 12 months.
D2928
Prefabricated porcelain/ceramic crown – permanent tooth
D2929
Prefabricated porcelain/ceramic crown – primary tooth: once in 12 months
D2930
Prefabricated stainless steel crown - primary tooth: once in 12 months
D2931
Prefabricated stainless steel crown - permanent tooth; once in 36 months
D2932
Prefabricated resin crown: once in 12 months for primary teeth, once in 36 months for permanent teeth
D2933
Prefabricated stainless steel crown with resin window: once in 12 months for primary teeth, once in 36 months for
permanent teeth
D2940
Protective restoration: once per tooth in 6 months per provider
D2941
Interim therapeutic restoration - primary dentition: once per tooth in 6 months per provider
D2949
Restorative foundation for an indirect restoration
D2950
Core buildup, including any pins when required
D2951
Pin retention - per tooth, in addition to restoration: once per tooth for permanent teeth
D2952
Post and core in addition to crown, indirectly fabricated: once per tooth
D2953
Each additional indirectly fabricated post - same tooth
D2954
Prefabricated post and core in addition to crown: once per tooth
D2955
Post removal
D2957
Each additional prefabricated post - same tooth
D2971
Additional procedures to customize a crown to fit under an existing partial denture framework
D2980
Crown repair necessitated by restorative material failure
D2999
Unspecified restorative procedure, by report
D4355
Full mouth debridement to enable comprehensive evaluation and diagnosis
D4910
Periodontal maintenance: once in a calendar quarter and only in the 24 months following the last scaling and root
planing, age 13+
D6081
Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the
implant surfaces, without flap entry and closure: once per tooth in 24 months
D7922
Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site
D9110
Palliative (emergency) treatment of dental pain - minor procedure: once per date of service per provider regardless
of the number of teeth and/or areas treated
D9120
Fixed partial denture sectioning
D9210
Local anesthesia not in conjunction with operative or surgical procedures: once per date of service per provider
D9211
Regional block anesthesia
D9212
Trigeminal division block anesthesia
D9215
Local anesthesia in conjunction with operative or surgical procedures
D9222
Deep sedation/general anesthesia – first 15 minutes
D9223
Deep sedation/general anesthesia – each 15 minute increment
D9230
Inhalation of nitrous oxide/anxiolysis, analgesia
XIAtBhi-CA-ENT-23 11
D9239
Intravenous moderate (conscious) sedation/analgesia – first 15 minutes
D9243
Intravenous moderate (conscious) sedation/analgesia – each 15 minute increment
D9248
Non-intravenous conscious sedation: once per date of service
D9410
House/extended care facility call: once per patient per date of service
D9420
Hospital or ambulatory surgical center call
D9430
Office visit for observation (during regularly scheduled hours) - no other services performed: once per date of
service per provider
D9440
Office visit - after regularly scheduled hours: once per date of service per provider
D9610
Therapeutic parenteral drug, single administration: maximum of 4 injections per date of service
D9612
Therapeutic parenteral drugs, two or more administrations, different medications
D9910
Application of desensitizing medicament: once in 12 months per provider for permanent teeth
D9930
Treatment of complications (post-surgical) - unusual circumstances, by report: once per date of service per provider
D9951
Occlusal adjustment - limited: once in 12 months, age 13+
D9999
Unspecified adjunctive procedure, by report
Major Services
D2710
Crown - resin-based composite (indirect): once in 5 years, age 13+
D2712
Crown - 3/4 resin-based composite (indirect): once in 5 years, age 13+
D2721
Crown - resin with predominantly base metal: once in 5 years, age 13+
D2740
Crown - porcelain/ceramic substrate: once in 5 years, age 13+
D2751
Crown - porcelain fused to predominantly base metal: once in 5 years, age 13+
D2781
Crown - 3/4 cast predominantly base metal: once in 5 years, age 13+
D2783
Crown - 3/4 porcelain/ceramic: once in 5 years, age 13+
D2791
Crown - full cast predominantly base metal: once in 5 years, age 13+
D3110
Pulp cap - direct (excluding final restoration)
D3120
Pulp cap - indirect (excluding final restoration)
D3220
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and
application of medicament: once per primary tooth
D3221
Pulpal debridement, primary and permanent teeth: once per tooth
D3222
Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development: once per permanent
tooth
D3230
Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration): once per primary tooth
D3240
Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration): once per primary tooth
D3310
Endodontic therapy, anterior tooth (excluding final restoration): once per tooth for initial root canal treatment
(root canal therapy retreatment processed as D3346)
D3320
Endodontic therapy, bicuspid tooth (excluding final restoration): once per tooth for initial root canal treatment
(root canal therapy retreatment processed as D3347)
D3330
Endodontic therapy, molar (excluding final restoration): once per tooth for initial root canal treatment (root canal
therapy retreatment processed as D3348)
D3331
Treatment of root canal obstruction; non-surgical access
D3333
Internal root repair of perforation defects
D3346
Retreatment of previous root canal therapy - anterior
D3347
Retreatment of previous root canal therapy - bicuspid
D3348
Retreatment of previous root canal therapy - molar
D3351
Apexification/recalcification – initial visit (apical closure / calcific repair of perforations, root resorption, etc.): once
per permanent tooth
D3352
Apexification/recalcification - interim medication replacement: once per permanent tooth
D3410
Apicoectomy - anterior
D3421
Apicoectomy - bicuspid (first root)
XIAtBhi-CA-ENT-23 12
D3425
Apicoectomy - molar (first root)
D3426
Apicoectomy (each additional root)
D3430
Retrograde filling - per root
D3471
Surgical repair of root resorption - anterior
D3472
Surgical repair of root resorption – premolar
D3473
Surgical repair of root resorption – molar
D3910
Surgical procedure for isolation of tooth with rubber dam
D3999
Unspecified endodontic procedure, by report
D4210
Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant: once per
quadrant in 36 months, age 13+
D4211
Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant: once per
quadrant in 36 months, age 13+
D4249
Clinical crown lengthening - hard tissue
D4260
Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth
bounded spaces per quadrant: once per quadrant in 36 months, age 13+
D4261
Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth
bounded spaces per quadrant: once per quadrant in 36 months, age 13+
D4265
Biologic materials to aid in soft and osseous tissue regeneration, per site
D4341
Periodontal scaling and root planing - four or more teeth per quadrant: once per quadrant in 24 months; age 13+
D4342
Periodontal scaling and root planing - one to three teeth per quadrant: once per quadrant in 24 months; age 13+
D4381
Localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue, per tooth
D4920
Unscheduled dressing change (by someone other than treating dentist or their staff): included in fee for completed
service (D4210, D4211, D4260, D4261) if same provider. Once per patient to different provider.
D4999
Unspecified periodontal procedure, by report: age 13+
D5110
Complete denture - maxillary: once in 5 years
D5120
Complete denture - mandibular: once in 5 years
D5130
Immediate denture - maxillary: once per patient
D5140
Immediate denture - mandibular: once per patient
D5211
Maxillary partial denture - resin base (including any conventional clasps, rests and teeth): once in 5 years
D5212
Mandibular partial denture - resin base (including any conventional clasps, rests and teeth): once in 5 years
D5213
Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials,
rests and teeth): once in 5 years
D5214
Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials,
rests and teeth): once in 5 years
D5221
immediate maxillary partial denture – resin base (including retentive/clasping materials, rests and teeth): once in 5
years
D5222
immediate mandibular partial denture – resin base (including retentive/clasping materials, rests and teeth): once in
5 years
D5223
immediate maxillary partial denture – cast metal framework with resin denture bases (including retentive/clasping
materials, rests and teeth): once in 5 years
D5224
immediate mandibular partial denture – cast metal framework with resin denture bases (including
retentive/clasping materials, rests and teeth): once in 5 years
D5410
Adjust complete denture - maxillary: per provider, once per date of service and twice in 12 months
D5411
Adjust complete denture - mandibular: per provider, once per date of service and twice in 12 months
D5421
Adjust partial denture - maxillary: per provider, once per date of service and twice in 12 months
XIAtBhi-CA-ENT-23 13
D5422
Adjust partial denture - mandibular: per provider, once per date of service and twice in 12 months
D5511
Repair broken complete denture base, mandibular: per provider, once per arch per date of service and twice in 12
months
D5512
Repair broken complete denture base, maxillary: per provider, once per arch per date of service and twice in 12
months
D5520
Replace missing or broken teeth - complete denture (each tooth): per provider, 4 per arch per date of service and
twice per arch in 12 months
D5611
Repair resin denture base, mandibular: per provider, once per arch per date of service and twice per arch in 12
months
D5612
Repair resin denture base, maxillary: per provider, once per arch per date of service and twice per arch in 12
months
D5621
Repair cast partial framework, mandibular: per provider, once per arch per date of service and twice per arch in 12
months
D5622
Repair cast partial framework, maxillary: per provider, once per arch per date of service and twice per arch in 12
months
D5630
Repair or replace broken retentive clasping materials - per tooth: per provider, 3 per date of service and twice per
arch in 12 months
D5640
Replace broken teeth - per tooth: per provider, 4 per arch per date of service and twice per arch in 12 months
D5650
Add tooth to existing partial denture: per provider, 3 per date of service and once per tooth
D5660
Add clasp to existing partial denture - per tooth: per provider, 3 per date of service and twice per arch in 12 months
D5730
Reline complete maxillary denture (direct): once in 12 months
D5731
Reline complete mandibular denture (direct): once in 12 months
D5740
Reline maxillary partial denture (direct): once in 12 months
D5741
Reline mandibular partial denture (direct): once in 12 months
D5750
Reline complete maxillary denture (indirect): once in 12 months
D5751
Reline complete mandibular denture (indirect): once in 12 months
D5760
Reline maxillary partial denture (indirect): once in 12 months
D5761
Reline mandibular partial denture (indirect): once in 12 months
D5850
Tissue conditioning, maxillary: twice per prosthesis in 36 months
D5851
Tissue conditioning, mandibular: twice per prosthesis in 36 months
D5862
Precision attachment, by report: included in fee for prosthetic and restorative procedure and not separately
payable
D5863
Overdenture – complete maxillary: once in 5 years
D5864
Overdenture – partial maxillary: once in 5 years
D5865
Overdenture – complete mandibular: once in 5 years
D5866
Overdenture - partial mandibular: once in 5 years
D5899
Unspecified removable prosthodontic procedure, by report
D5911
Facial moulage (sectional)
D5912
Facial moulage (complete)
D5913
Nasal prosthesis
D5914
Auricular prosthesis
D5915
Orbital prosthesis
D5916
Ocular prosthesis
D5919
Facial prosthesis
D5922
Nasal septal prosthesis
D5923
Ocular prosthesis, interim
D5924
Cranial prosthesis
XIAtBhi-CA-ENT-23 14
D5925
Facial augmentation implant prosthesis
D5926
Nasal prosthesis, replacement
D5927
Auricular prosthesis, replacement
D5928
Orbital prosthesis, replacement
D5929
Facial prosthesis, replacement
D5931
Obturator prosthesis, surgical
D5932
Obturator prosthesis, definitive
D5933
Obturator prosthesis, modification: twice in 12 months
D5934
Mandibular resection prosthesis with guide flange
D5935
Mandibular resection prosthesis without guide flange
D5936
Obturator prosthesis, interim
D5937
Trismus appliance (not for TMD treatment)
D5951
Feeding aid
D5952
Speech aid prosthesis, pediatric
D5953
Speech aid prosthesis, adult
D5954
Palatal augmentation prosthesis
D5955
Palatal lift prosthesis, definitive
D5958
Palatal lift prosthesis, interim
D5959
Palatal lift prosthesis, modification: twice in 12 months
D5960
Speech aid prosthesis, modification: twice in 12 months
D5982
Surgical stent
D5983
Radiation carrier
D5984
Radiation shield
D5985
Radiation cone locator
D5986
Fluoride gel carrier
D5987
Commissure splint
D5988
Surgical splint
D5991
Vesiculobullous disease medicament carrier
D5999
Unspecified maxillofacial prosthesis, by report
D6010
Surgical placement of implant body: endosteal implant
D6011
Surgical access to an implant body (second stage implant surgery)
D6013
Surgical placement of mini implant
D6040
Surgical placement: eposteal implant
D6050
Surgical placement: transosteal implant
D6055
Connecting bar – implant supported or abutment supported
D6056
Prefabricated abutment – includes modification and placement
D6057
Custom fabricated abutment – includes placement
D6058
Abutment supported porcelain/ceramic crown
D6059
Abutment supported porcelain fused to metal crown (high noble metal)
D6060
Abutment supported porcelain fused to metal crown (predominantly base metal)
D6061
Abutment supported porcelain fused to metal crown (noble metal)
D6062
Abutment supported cast metal crown (high noble metal)
D6063
Abutment supported cast metal crown (predominantly base metal)
D6064
Abutment supported cast metal crown (noble metal)
D6065
Implant supported porcelain/ceramic crown
D6066
Implant supported crown- porcelain fused to high noble alloys
XIAtBhi-CA-ENT-23 15
D6067
Implant supported crown- high noble alloys
D6068
Abutment supported retainer for porcelain/ceramic FPD
D6069
Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
D6070
Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
D6071
Abutment supported retainer for porcelain fused to metal FPD (noble metal)
D6072
Abutment supported retainer for cast metal FPD (high noble metal)
D6073
Abutment supported retainer for cast metal FPD (predominantly base metal)
D6074
Abutment supported retainer for cast metal FPD (noble metal)
D6075
Implant supported retainer for ceramic FPD
D6076
Implant supported retainer FPD- porcelain fused to high noble alloys
D6077
Implant supported retainer for metal FPD- high noble alloys
D6080
Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses
and abutments
D6082
Implant supported crown - porcelain fused to predominantly base alloys
D6083
Implant supported crown - porcelain fused to noble alloys
D6084
Implant supported crown - porcelain fused to titanium and titanium alloys
D6085
Provisional implant crown: included in fee for implant services and not separately payable
D6086
Implant supported crown - predominantly base alloys
D6087
Implant supported crown - noble alloys
D6088
Implant supported crown - titanium and titanium alloys
D6090
Repair implant supported prosthesis, by report
D6091
Replacement of replaceable part of semi-precision or precision
attachment (male or female component) of implant/abutment supported
prosthesis, per attachment
D6092
Re-cement or re-bond implant/abutment supported crown: once in 12 months per provider
D6093
Re-cement or re-bond implant/abutment supported fixed partial denture: once in 12 months per provider
D6094
Abutment supported crown - titanium and titanium alloys
D6095
Repair implant abutment, by report
D6096
Remove broken implant retaining screw
D6097
Abutment supported crown - porcelain fused to titanium and titanium alloys
D6098
Implant supported retainer - porcelain fused to predominantly base alloys
D6099
Implant supported retainer for FPD - porcelain fused to noble alloys
D6100
Surgical removal of implant body
D6110
Implant/abutment supported removable denture for edentulous arch – maxillary
D6111
Implant/abutment supported removable denture for edentulous arch – mandibular
D6112
Implant/abutment supported removable denture for partially edentulous arch – maxillary
D6113
Implant/abutment supported removable denture for partially edentulous arch – mandibular
D6114
Implant/abutment supported fixed denture for edentulous arch – maxillary
D6115
Implant/abutment supported fixed denture for edentulous arch – mandibular
D6116
Implant/abutment supported fixed denture for partially edentulous arch – maxillary
D6117
Implant/abutment supported fixed denture for partially edentulous arch – mandibular
D6120
Implant supported retainer – porcelain fused to titanium and titanium alloys
D6121
Implant supported retainer for metal FPD – predominantly base alloys
D6122
Implant supported retainer for metal FPD – noble alloys
D6123
Implant supported retainer for metal FPD – titanium and titanium alloys
D6190
Radiographic/surgical implant index, by report
D6191
Semi-precision abutment – placement
XIAtBhi-CA-ENT-23 16
D6192
Semi-precision attachment – placement
D6194
Abutment supported retainer crown for FPD- titanium and titanium alloys
D6195
Abutment supported retainer - porcelain fused to titanium and titanium alloys
D6199
Unspecified implant procedure, by report
D6211
Pontic - cast predominantly base metal: once in 5 years, age 13+
D6241
Pontic - porcelain fused to predominantly base metal: once in 5 years, age 13+
D6245
Pontic - porcelain/ceramic: once in 5 years, age 13+
D6251
Pontic - resin with predominantly base metal: once in 5 years, age 13+
D6721
Retainer crown - resin with predominantly base metal: once in 5 years, age 13+
D6740
Retainer crown - porcelain/ceramic: once in 5 years, age 13+
D6751
Retainer crown - porcelain fused to predominantly base metal: once in 5 years, age 13+
D6781
Retainer crown - 3/4 cast predominantly base metal: once in 5 years, age 13+
D6783
Retainer crown - 3/4 porcelain/ceramic: once in 5 years, age 13+
D6784
Retainer crown ¾ - titanium and titanium alloys: once in 5 years, age 13+
D6791
Retainer crown - full cast predominantly base metal: once in 5 years, age 13+
D6930
Re-cement or re-bond fixed partial denture: once in 12 months per same provider
D6980
Fixed partial denture repair necessitated by restorative material failure: once in 12 months of initial placement or
previous repair by same provider
D6999
Unspecified fixed prosthodontic procedure, by report: once in 12 months of initial placement by same provider
D7111
Extraction, coronal remnants - deciduous tooth
D7140
Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
D7210
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of
mucoperiosteal flap if indicated
D7220
Removal of impacted tooth - soft tissue
D7230
Removal of impacted tooth - partially bony
D7240
Removal of impacted tooth - completely bony
D7241
Removal of impacted tooth - completely bony, with unusual surgical complications
D7250
Surgical removal of residual tooth roots (cutting procedure)
D7260
Oroantral fistula closure
D7261
Primary closure of a sinus perforation
D7270
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth: once per arch regardless of
the number of teeth involved for permanent anterior teeth
D7280
Exposure of an unerupted tooth
D7283
Placement of device to facilitate eruption of impacted tooth
D7285
Incisional biopsy of oral tissue -hard (bone, tooth): once per arch per date of service
D7286
Incisional biopsy of oral tissue -soft: maximum of 3 per date of service
D7290
Surgical repositioning of teeth: once per arch for permanent teeth for patients in active orthodontic treatment
D7291
Transseptal fiberotomy/supra crestal fiberotomy, by report: once per arch
D7310
Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
D7311
Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
D7320
Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
D7321
Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant
D7340
Vestibuloplasty - ridge extension (secondary epithelialization): once per arch in 5 years
XIAtBhi-CA-ENT-23 17
D7350
Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue
attachment and management of hypertrophied and hyperplastic tissue): once per arch
D7410
Excision of benign lesion up to 1.25 cm
D7411
Excision of benign lesion greater than 1.25 cm
D7412
Excision of benign lesion, complicated
D7413
Excision of malignant lesion up to 1.25 cm
D7414
Excision of malignant lesion greater than 1.25 cm
D7415
Excision of malignant lesion, complicated
D7440
Excision of malignant tumor - lesion diameter up to 1.25 cm
D7441
Excision of malignant tumor - lesion diameter greater than 1.25 cm
D7450
Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm
D7451
Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm
D7460
Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm
D7461
Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm
D7465
Destruction of lesion(s) by physical or chemical method, by report
D7471
Removal of lateral exostosis (maxilla or mandible): once per quadrant
D7472
Removal of torus palatinus: once in the patient's lifetime
D7473
Removal of torus mandibularis: once per quadrant
D7485
Reduction of osseous tuberosity: once per quadrant
D7490
Radical resection of maxilla or mandible
D7510
Incision and drainage of abscess - intraoral soft tissue: once per quadrant per same date of service
D7511
Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces):
once per quadrant per same date of service
D7520
Incision and drainage of abscess - extraoral soft tissue
D7521
Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces)
D7530
Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue: once per date of service
D7540
Removal of reaction producing foreign bodies, musculoskeletal system: once per date of service
D7550
Partial ostectomy/sequestrectomy for removal of non-vital bone: once per quadrant per date of service
D7560
Maxillary sinusotomy for removal of tooth fragment or foreign body
D7610
Maxilla - open reduction (teeth immobilized, if present)
D7620
Maxilla - closed reduction (teeth immobilized, if present)
D7630
Mandible - open reduction (teeth immobilized, if present)
D7640
Mandible - closed reduction (teeth immobilized, if present)
D7650
Malar and/or zygomatic arch - open reduction
D7660
Malar and/or zygomatic arch - closed reduction
D7670
Alveolus closed reduction may include stabilization of teeth
D7671
Alveolus, open reduction may include stabilization of teeth
D7680
Facial bones - complicated reduction with fixation and multiple surgical approaches
D7710
Maxilla open reduction
D7720
Maxilla - closed reduction
D7730
Mandible - open reduction
D7740
Mandible - closed reduction
D7750
Malar and/or zygomatic arch - open reduction
D7760
Malar and/or zygomatic arch - closed reduction
XIAtBhi-CA-ENT-23 18
D7770
Alveolus - open reduction stabilization of teeth
D7771
Alveolus, closed reduction stabilization of teeth
D7780
Facial bones - complicated reduction with fixation and multiple surgical approaches
D7810
Open reduction of dislocation
D7820
Closed reduction of dislocation
D7830
Manipulation under anesthesia
D7840
Condylectomy
D7850
Surgical discectomy, with/without implant
D7852
Disc repair
D7854
Synovectomy
D7856
Myotomy
D7858
Joint reconstruction
D7860
Arthrotomy
D7865
Arthroplasty
D7870
Arthrocentesis
D7871
Non-arthroscopic lysis and lavage
D7872
Arthroscopy - diagnosis, with or without biopsy
D7873
Arthroscopy: lavage and lysis of adhesions
D7874
Arthroscopy: disc repositioning and stabilization
D7875
Arthroscopy: synovectomy
D7876
Arthroscopy: discectomy
D7877
Arthroscopy: debridement
D7880
Occlusal orthotic device, by report
D7881
Occlusal orthotic device adjustment: once per date of service per provider, two in 12 months per provider
D7899
Unspecified TMD therapy, by report
D7910
Suture of recent small wounds up to 5 cm
D7911
Complicated suture - up to 5 cm
D7912
Complicated suture - greater than 5 cm
D7920
Skin graft (identify defect covered, location and type of graft)
D7940
Osteoplasty - for orthognathic deformities
D7941
Osteotomy - mandibular rami
D7943
Osteotomy - mandibular rami with bone graft; includes obtaining the graft
D7944
Osteotomy - segmented or subapical
D7945
Osteotomy - body of mandible
D7946
Lefort I (maxilla - total)
D7947
Lefort I (maxilla - segmented)
D7948
Lefort II or lefort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft
D7949
Lefort II or lefort III - with bone graft
D7950
Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report
D7951
Sinus augmentation with bone or bone substitutes via a lateral open approach
D7952
Sinus augmentation via a vertical approach
D7955
Repair of maxillofacial soft and/or hard tissue defect
D7961
Buccal / labial frenectomy (frenulectomy)
D7962
Lingual frenectomy (frenulectomy)
D7963
Frenuloplasty: once per arch per date of service
XIAtBhi-CA-ENT-23 19
D7970
Excision of hyperplastic tissue - per arch: once per arch per date of service
D7971
Excision of pericoronal gingiva
D7972
Surgical reduction of fibrous tuberosity: once per quadrant per date of service
D7979
Non-surgical sialolithotomy
D7980
Sialolithotomy
D7981
Excision of salivary gland, by report
D7982
Sialodochoplasty
D7983
Closure of salivary fistula
D7990
Emergency tracheotomy
D7991
Coronoidectomy
D7995
Synthetic graft - mandible or facial bones, by report
D7997
Appliance removal (not by dentist who placed appliance), includes removal of archbar: once per arch per date of
service
D7999
Unspecified oral surgery procedure, by report
D9950
Occlusion analysis - mounted case: once in 12 months, age 13+
D9952
Occlusal adjustment - complete: once in 12 months, age 13+
Orthodontia
D8080
Comprehensive orthodontic treatment of the adolescent dentition: once per patient per phase of treatment
D8210
Removable appliance therapy: once per patient, ages 6 through 12
D8220
Fixed appliance therapy: once per patient, ages 6 through 12
D8660
Pre-orthodontic treatment examination to monitor growth and development: once every 3 months for a maximum
of 6 during patient's lifetime
D8670
Periodic orthodontic treatment visit: once per calendar quarter
D8680
Orthodontic retention (removal of appliances, construction and placement of retainer(s): once per arch for each
authorized phase of orthodontic treatment
D8681
Removable orthodontic retainer adjustment. Included in fee for complete orthodontic service and not separately
payable.
D8696
Repair of orthodontic appliance – maxillary: once per appliance
D8697
Repair of orthodontic appliance – mandibular: once per appliance
D8698
Re-cement or re-bond fixed retainer – maxillary: once per provider
D8699
Re-cement or re-bond fixed retainer – mandibular: once per provider
D8701
Repair of fixed retainer, includes reattachment – maxillary: Included in fee for complete orthodontic service and
not separately payable.
D8702
Repair of fixed retainer, includes reattachment – mandibular: Included in fee for complete orthodontic service and
not separately payable.
D8703
Replacement of lost or broken retainer – maxillary: once per arch
D8704
Replacement of lost or broken retainer – mandibular: once per arch
D8999
Unspecified orthodontic procedure, by report
Limitations for Pediatric Benefits (under age 19)
(1) Claims shall be processed in accordance with Delta Dental's standard processing policies. The processing
policies may be revised from time to time; therefore, Delta Dental shall use the processing policies that
are in effect at the time the claim is processed. Delta Dental may use dentists (dental consultants) to
review treatment plans, diagnostic materials and/or prescribed treatments to determine generally
accepted dental practices and to determine if treatment has a favorable prognosis.
XIAtBhi-CA-ENT-23 20
(2) If a primary dental procedure includes component procedures that are performed at the same time as the
primary procedure, the component procedures are considered to be part of the primary procedure for
purposes of determining the benefit payable under this Policy. If the Provider bills separately for the
primary procedure and each of its component parts, the total benefit payable for all related charges will
be limited to the maximum benefit payable for the primary procedure.
(3) Exam(covered codes only between D0120 – D0180) and cleaning limitations(D1110, D1120):
a) Delta Dental will pay for periodic oral examinations(D0120) (except after hours exams(D9440) and
exams for observation(D9430)) no more than once every six (6) months per provider and routine
cleanings(D1110, D1120), including scaling in presence of generalized moderate or severe gingival
inflammation(D4346) (including periodontal maintenance(D4910) or any combination thereof) no
more than once every six (6) months. Detailed(D0160), limited(D0140) and comprehensive(D0150,
D0180) oral examinations are covered once per patient per provider. Re-evaluation – limited,
problem focused exams (established patient; not post-operative visits)(D0170) are covered up to six
(6) times in a three (3) month period and up to a maximum of 12 in a 12 month period. This
procedure is not a benefit when provided on the same date of service with a detailed and extensive
oral evaluation. See note on additional Benefits during pregnancy.
b) Periodontal maintenance(D4910) is limited to Enrollees age 13 and older once in a calendar quarter
and only in the 24 months following the last scaling and root planing. A full mouth
debridement(D4355) is included in in the fee for other periodontal procedures and is not payable
separately.
c) Note that periodontal maintenance(D4910), Procedure Codes that include periodontal maintenance
and full mouth debridement(D4355) are covered as a Basic Benefit, and routine cleanings(D1110,
D1120) including scaling in presence of generalized moderate or severe gingival inflammation(D4346)
are covered as a Diagnostic and Preventive Benefit. Periodontal maintenance(D4910) is only covered
when performed following active periodontal therapy(D4260, D4261, D4341, D4342).
d) Caries risk assessments(D0601, D0601,D0603) are allowed once in 12 months.
e) Interim caries arresting medicament applications(D1354) are covered once per tooth every six (6)
months when Enrollee has a caries risk assessment and documentation with a finding of high risk.
(4) X-ray limitations:
a) Delta Dental will limit the total reimbursable amount to the Provider’s Accepted Fee for a complete
intraoral series(D0210) when the fees for any combination of intraoral x-rays(D0220 – D0240) in a
single treatment series meet or exceed the Accepted Fee for a complete intraoral series.
b) When a panoramic film(D0330) is submitted with supplemental film(s)(D0220, D0230, D0270-D0274,
D0277), Delta Dental will limit the total reimbursable amount to the Provider's Accepted Fee for a
complete intraoral series(D0210).
c) If a panoramic film(D0330) is taken in conjunction with an intraoral complete series (D0210), Delta
Dental considers the panoramic film to be included in the complete series.
d) Intraoral - periapical radiographic images(D0220,D0230) are limited to a maximum of 20 in any 12
month period. Intraoral - occlusal radiographic images(D0240) are limited to two (2) in any six (6)
month period.
e) A complete intraoral series(D0210) and panoramic film(D0330) are each limited to once every 36
months per provider. Additional panoramic films may be allowed when documented as essential for a
follow-up/post-operative exam (such as after oral surgery).
f) Bitewing x-rays, single radiographic image(D0270) is limited to once per date of service. Bitewing -
two or more radiographic images(D0272 – D0277), are limited to once every six (6) months per
provider. Bitewing - four radiographic images(D0274) are limited to Enrollees age 10 and older.
Bitewings – two or more radiographic images are not billable to the Enrollee or Delta Dental within
six (6) months of a full mouth series unless warranted by special circumstances.
g) Image capture procedures are not separately allowable services.
(5) Cephalometric x-rays(D0340) and tomographic surveys(D0322) are covered twice (2) in any 12 month
period per provider. Diagnostic casts(D0470) are covered only for the evaluation of Orthodontic Services
and are provided once per provider unless special circumstances are documented (such as trauma or
XIAtBhi-CA-ENT-23 21
pathology which has affected the course of orthodontic treatment). See Orthodontic Limitations as age
limits may apply. 3D x-rays(D0351) are covered once per date of service.
(6) The fee for pulp vitality tests(D0460) is included in the fees for diagnostic(covered codes only between
D0100 – D0999), restorative(covered codes only between D2000 – 2999), endodontic(covered codes only
between 3000 – D3999) and emergency procedures(D9110) and is not payable separately.
(7) Topical application of fluoride solutions(D1206,D1208) is limited to once in a six (6) month period.
(8) Space maintainer limitations(D1510 – D1575):
a) Except for distal shoe space maintainers(D1575), space maintainers(D1510,D1520) are limited to
Enrollees through age 17 and covered once per quadrant in a lifetime, except bilateral space
maintiners(D1516, D1517, D1526, D1527) which are covered once per arch.
b) Distal shoe space maintainer - fixed – unilateral(D1575) is limited to children 8 and younger and is
limited to once per quadrant per lifetime. A separate/additional space maintainer can be allowed
after the removal of a unilateral distal shoe.
c) Recementation of space maintainer(D1551, D1552, D1553) is limited to once per provider per
applicable arch or quadrant.
d) The removal of a fixed space maintainer(D1556, D1557, D1558) is considered to be included in the
fee for the space maintainer; however, an exception is made if the removal is performed by a
different Provider/Provider’s office.
(9) Sealants(D1351) are limited as follows:
a) once per tooth per provider every 36 months and only to permanent molars if they are without caries
(decay) or restorations on the occlusal surface.
b) repair(D1353) or replacement(D1351) of a Sealant on any tooth within 36 months of its application is
included in the fee for the original placement by the original provider.
(10) Delta Dental will not cover replacement of an amalgam(D2140 –D2161), prefabricated crown(D2929 –
D2934) or resin-based composite restorations (fillings)(D2330 –D2394) within 12 months of treatment for
primary teeth or 36 months of treatment for permanent teeth. Replacement restorations within 12
months for primary teeth and within 24 months for permanent teeth are included in the fee for the
original restoration.
(11) Protective restorations (sedative fillings)(D2940) are allowed once per tooth per provider in a six (6)
month period when definitive treatment is not performed on the same date of service. The fee for
protective restorations are included in the fee for any definitive treatment performed on the same date.
(12) Therapeutic pulpotomy(D3220) is limited to once per tooth per lifetime for baby (deciduous) teeth only;
an allowance for an emergency palliative treatment(D9110) is made when performed on permanent
teeth.
(13) Pulpal therapy (resorbable filling)(D3230, D3240) for anterior primary teeth and pulpal debridement for
primary and permanent teeth(D3221) are limited to once per tooth per lifetime. Retreatment of root
canal therapy(D3346 – D3348) by the same Provider/Provider office within 12 months is considered part
of the original procedure.
(14) Apexification(D3351 – D3352) is only benefited on permanent teeth with incomplete root canal
development or for the repair of a perforation. Apexification visits have a lifetime limit per tooth with the
fee for the final visit included in the fee for the final root canal.
(15) Retreatment of apical surgery(D3410, D3421,D3425, D3426, D3430) by the same Provider/Provider office
within 24 months is considered part of the original procedure.
(16) Pin retention(D2951) is covered once per tooth per lifetime for permanent teeth. Fees for additional pins
on the same tooth on the same date are considered a component of the initial pin placement.
(17) Palliative treatment(D9110) is allowed once per date of service per provider regardless of the number of
teeth and/or areas treated, and the fee for palliative treatment provided in conjunction with any
XIAtBhi-CA-ENT-23 22
procedures other than x-rays or select Diagnostic procedures is considered included in the fee for the
definitive treatment.
(18) Periodontal limitations(covered codes only between D4000 – D4999):
a) Benefits for periodontal scaling and root planing(D4341, D4342) in the same quadrant are limited to
once in every 24-month period for Enrollees age 13 and older.
b) Periodontal surgery(covered codes only between D4210 – D4265) in the same quadrant is limited to
once in every 36-month period for Enrollees age 13 and older and includes any surgical re-entry or
scaling and root planing(D4341, D4342) performed within 36-months by the same dentist/dental
office.
c) Periodontal services, including covered graft procedures are only covered for the treatment of
natural teeth and are not covered when submitted in conjunction with extractions(D7111,
D7140,D7210, D7220, D7230, D7240, D7241, D7250), periradicular surgery (covered codes only
between D3410-D3430), ridge augmentation(D7340, D7350, D7950-D7952) or implants (covered
codes only between D6010-D6050).
d) Periodontal surgery(covered codes only between D4210 – D4265) is subject to a 30 day wait
following periodontal scaling and root planing(D4341, D4342) in the same quadrant.
e) Cleanings (regular and periodontal)(D1110, D1120,D4346, D4910) and full mouth debridement D4355
are subject to a 30 day wait following periodontal scaling and root planing(D4341, D4342) if
performed by the same Provider office.
f) When implant procedures(covered codes only between D6000 – D6199) are a covered benefit,
scaling and debridement in the presence of inflammation or mucositis of a single implant, including
cleaning of the implant surfaces, without flap entry and closure(D6081) is covered as a basic benefit
and are limited to once in a 24-month period.
(19) Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth(D7270) are covered
once per arch regardless of number of teeth invovled for permanent, anterior teeth only.
(20) Surgical repositioning(D7290) of teeth and transseptal fiberotomy/supra crestal fiberotomy (D7291), by
report procedures are covered once per arch for permanent teeth for patients in active orthodontic
treatment.
(21) Vestibuloplasty - ridge extension (secondary epithelialization)(D7340) is covered once per arch in a five (5)
year period. Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision
of soft tissue attachment and management of hypertrophied and hyperplastic tissue)(D7350) is covered
once per arch in a lifetime.
(22) Removal of lateral exostosis (maxilla or mandible)(D7471) and of torus madibularis(D7473), as well as the
surgical reduction of osseous tuberosity(D7485), are limited to once per quadrant per lifetime. Removal of
torus palatinus(D7472) is limited to once per lifetime.
(23) Incision and drainage of abscess – intraoral soft tissue(D7510, D7511) is limited to one (1) per quadrant on
the same date of service.
(24) Partial ostectomy/sequestrectomy for removal of non-vital bone(D7550) is limited to on (1) per quadrant
on the same date of service.
(25) Palatal lift prosthesis modification(D5959) and speech aid prosthesis modification(D5960) are limited to
twice in a 12 month period.
(26) Crowns(covered codes D2710 – D2794), excluding prefabricated crowns (covered codes only
betweenD2929 – D2934), are limited to Enrollees age 13 and older and are covered not more often than
once in a five (5) year period except when Delta Dental determines the existing Crown is not satisfactory
and cannot be made satisfactory because the tooth involved has experienced extensive loss or changes to
tooth structure or supporting tissues. Services will only be allowed on teeth that are developmentally
mature.
(27) Post and core services(covered codes only between D2952 - D2957) are covered once per tooth in a
lifetime on permanent teeth.
XIAtBhi-CA-ENT-23 23
(28) Crown repairs(D2980) are are not a benefit within 12 months of initial crown placement or previous repair
for the same provider.
(29) When allowed within six (6) months of a restoration(D2140-D2161, D2330-D2335, D2391-D2394), the
Benefit for a Crown, Inlay/Onlay(covered codes only between D2510 – D2794) or fixed prosthodontic
service(covered codes only between D6200- D6999) will be reduced by the Benefit paid for the
restoration.
(30) Removable Denture Repairs(D5511, D5512, D5611, D5612, D5621, D5622) are covered once per arch per
date of service per provider and not more than twice in any twelve (12) month period per provider.
Adding teeth to an existing partial denture (D5650) is covered once per tooth and is limited to a maximum
of three (3) per date of service per provider.
(31) Implant services(covered codes only between D6000 – D6199) are a benefit only when exceptional
medical conditions are documented and shall be reviewed by the Delta Dental for medical necessity for
prior authorization. Diagnostic and treatment facilitating aids for implants are considered a part of, and
included in, the fees for the definitive treatment. Exceptional medical conditions include, but are not
limited to:
a) cancer of the oral cavity requiring ablative surgery and/or radiation leading to destruction of alveolar
bone, where the remaining osseous structures are unable to support conventional dental prostheses.
b) severe atrophy of the mandible and/or maxilla that cannot be corrected with vestibular extension
procedures or osseous augmentation procedures, and the patient is unable to function with
conventional prostheses.
c) skeletal deformities that preclude the use of conventional prostheses (such as arthrogryposis,
ectodermal dysplasia, partial anaodontia and cleidocranial dysplasia).
d) traumatic destruction of jaw, face or head where the remaining osseous structures are unable to
support conventional dental prostheses.
(32) Fixed partial dentures (bridgework) (D6211, D6241, D6245, D6251, D6721, D6740, D6751, D6781, D6783,
D6784, D6791, D6930, D6980, D6999) are not generally covered but shall be considered for prior
authorization only when medical conditions or employment preclude the use of a removable partial
denture(covered codes only between D5211 – D5283). The Enrollee shall first meet the criteria for a
removable partial denture before a fixed partial denture will be considered. Approved fixed partial
dentures are a benefit once in a 60 month period and only for Enrollees age 13 and older.
Medical conditions, which preclude the use of a removable partial denture, include:
a) the epileptic patient where a removable partial denture could be injurious to their health during an
uncontrolled seizure,
b) the paraplegia patient who utilizes a mouth wand to function to any degree and where a mouth wand
is inoperative because of missing natural teeth,
c) patients with neurological disorders whose manual dexterity precludes proper care and maintenance
of a removable partial denture.
(33) Prosthodontics(D5110, D5120, D5211 – D5224, D5863 – D5866) (covered codes only between D6211 –
D6791) that were provided under any Delta Dental program will be replaced only after five (5) years have
passed, except when Delta Dental determines that there is such extensive loss of remaining teeth or
change in supporting tissue that the existing fixed bridge or denture cannot be made satisfactory.
Immediate dentures are a benefit once per patient per lifetime. Replacement of a prosthodontic
appliance(D5110, D5120, D5211 – D5224, covered codes only between D6211 – D6791) and/or implant
supported prosthesis(D6058-D6077, D6094, D6110-D6117) not provided under a Delta Dental program
will be made if Delta Dental determines it is unsatisfactory and cannot be made satisfactory. Services will
only be allowed on teeth that are developmentally mature.
(34) When a posterior fixed bridge(covered codes only between D6205 – D6794) and a removable partial
denture(D5211 – D5283) are placed in the same arch in the same treatment episode, only the partial
denture will be a Benefit.
(35) Recementation of Crowns, Inlays/Onlays or bridges(D2910, D2915, D2920, D6930) is included in the fee
for the Crown, Inlay/Onlay or bridge(covered codes only between D2510 – D2794, D6205 – D6974) when
XIAtBhi-CA-ENT-23 24
performed by the same Provider/Provider office within 12 months of the initial placement. After 12
months, payment will be limited to one (1) recementation in a 12 month period by the same
Provider/Provider office.
(36) The initial installation of a prosthodontic appliance(covered codes only between D5000 – D5899, D6100 –
D6999) and/or implants(covered codes only between D6000 D6199) and/or implants is not a Benefit
unless the prosthodontic appliance and/or implant, bridge or denture is made necessary by natural,
permanent teeth extraction occurring during a time the Enrollee was under a Delta Dental plan.
(37) TMJ dysfunction procedures are limited to differential diagnosis(covered codes only between D0310-
D0322) and symptomatic care(covered codes only between D7810-D7899). Not included as a benefit are
those TMJ treatment modalities that involve prosthodontia(D5110, D5120, D5211 – D5224, covered codes
only between D6211 – D6791), orthodontia(covered codes only between D8000 – D8999) and full or
partial occlusal rehabilitation.
(38) Occlusion analysis – mounted case(D9950), and occlusal adjustments, limited(D9951) and
complete(D9952), are limited to one (1) in 12 months for diagnosed TMJ disfunction for permanent
dentition and only for Enrollees age 13 and older.
(39) Application of desensitizing medicament(D9951) is limited to once in a 12 month period for permanent
teeth only.
(40) Delta Dental limits payment for dentures(covered codes only between D5000 – D5899) to a standard
partial(covered codes only between D5211 – D5283) or complete denture(D5110 – D5140) (Enrollee
Coinsurances apply). A standard denture means a removable appliance to replace missing natural,
permanent teeth that is made from acceptable materials by conventional means and includes routine
post delivery care including any adjustments(D5410 – D5422) for the first six (6) months after placement
and relines(D5730 – D5761) for the first 12 months after placement.
a) Dentures, removable partial dentures(D5211 – D5283) and relines include adjustments for six (6)
months following installation. After the initial six (6) months of an adjustment, adjustments are
limited to twice in a 12 month period per provider and relining is limited to once in a 12 month
period.
b) Tissue conditioning(D5850, D5851) is limited to two (2) per prosthesis in a 36 month period.
However, tissue conditioning is not allowed as a separate Benefit when performed on the same day
as a denture reline service.
c) Recementation of fixed partial dentures(D6930) is not a benefit within 12 months of a previous re-
cementation by the same provider.
(41) Limitations on Orthodontic Services(covered codes only between D8000 – D8999):
a) Services are limited to medically necessary orthodontics when provided by a Provider. Orthodontic
treatment is a benefit of this dental plan only when medically necessary as evidenced by a severe
handicapping malocclusion and when a prior authorization is obtained.
b) Orthodontic procedures are a benefit only when the diagnostic casts verify a minimum score of 26
points on the Handicapping Labio-Lingual Deviation (HLD) Index or one of the automatic qualifying
conditions below exist.
c) The automatic qualifying conditions are:
i) Cleft palate deformity. If the cleft palate is not visible on the diagnostic casts written
documentation from a credentialed specialist shall be submitted, on their professional
letterhead, with the prior authorization request,
ii) Craniofacial anomaly. Written documentation from a credentialed specialist shall be submitted,
on their professional letterhead, with the prior authorization request,
iii) A deep impinging overbite in which the lower incisors are destroying the soft tissue of the
palate,
iv) A crossbite of individual anterior teeth causing destruction of soft tissue,
v) An overjet greater than 9 mm or reverse overjet greater than 3.5 mm,
vi) Severe traumatic deviation.
XIAtBhi-CA-ENT-23 25
d) The following documentation must be submitted with the request for prior authorization of services
by the Provider:
i) ADA 2006 or newer Claim Form with service code(s) requested;
ii) Diagnostic study models (trimmed) with bite registration; or OrthoCad equivalent;
iii) Cephalometric radiographic image or panoramic radiographic image;
iv) HLD score sheet completed and signed by the Orthodontist; and
v) Treatment plan.
e) The allowances for comprehensive orthodontic treatment procedures (D8080) include all appliances,
adjustments, insertion, removal and post treatment stabilization (retention) (D8680). No additional
charge to the Enrollee is permitted.
f) Comprehensive orthodontic treatment(D8080) includes the replacement, repair and removal of
brackets, bands and arch wires by the original Provider.
g) Orthodontic procedures are Benefits for medically necessary handicapping malocclusion, cleft palate
and facial growth management cases for Enrollees under the age of 19 and shall be prior authorized.
h) Only those cases with permanent dentition shall be considered for medically necessary handicapping
malocclusion, unless the Enrollee is age 13 or older with primary teeth remaining. Cleft palate and
craniofacial anomaly cases are a benefit for primary, mixed and permanent dentitions. Craniofacial
anomalies are treated using facial growth management.
i) All necessary procedures that may affect orthodontic treatment shall be completed before
orthodontic treatment is considered.
j) Pre-orthodontic treatment vists(D8660) are allowed once every three (3) months up to a maximum of
six (6) per Enrollee.
k) Removable and fixed appliance therapy(D8210,D8220) are allowed once per Enrollee age six (6) to
12.
l) When specialized orthodontic appliances or procedures chosen for aesthetic considerations are
provided (Covered codes only between D8000-D8999), Delta Dental will make an allowance for the
cost of a standard orthodontic treatment. The Enrollee is responsible for the difference between the
allowance made towards the standard orthodontic treatment and the dentist’s charge for the
specialized orthodontic appliance or procedure.
m) Repair of an orthodontic appliance(D8696, D8697) inserted under this dental plan is covered once per
appliance. The replacement of an orthodontic appliance inserted under this dental plan is covered
once per arch.
n) Replacement of a lost or broken retainer(D8703, D8704) is a benefit once per arch and only within 24
months following date of service of orthodontic retention.
o) The removal of fixed orthodontics appliances(D8695) for reasons other than completion of treatment
is not a covered benefit.
Exclusions for Pediatric Benefits (under age 19)
Delta Dental does not pay Benefits for:
(1) services that are not Essential Health Benefits except as required by state or federal law.
(2) treatment of injuries or illness covered by workers' compensation or employers' liability laws;services
received without cost from any federal, state or local agency, unless this exclusion is prohibited by law.
(3) cosmetic surgery or procedures for purely cosmetic reasons(D9972-D9975, D2960-D2962), (exclude
covered codes in this list if done for purely cosmetic reasons: D2710–D2751, D2940, D2330–D2394,
D8000-D8999).
(4) provisional and/or temporary restorations(D2799). Provisional and/or temporary restorations are not
separately payable procedures and are included in the fee for completed service.
(5) services for congenital (hereditary) or developmental (following birth) malformations, including but not
limited to cleft palate, upper and lower jaw malformations, enamel hypoplasia (lack of development),
fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), except those
services provided to children for medically diagnosed congenital defects or birth abnormalities.
XIAtBhi-CA-ENT-23 26
(6) treatment to stabilize teeth(D7272), treatment to restore tooth structure lost from wear, erosion, or
abrasion or treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion.
Examples include but are not limited to: periodontal splinting(D4322, D4323) or fixed bridge
procedures(D6252–D6720).
(7) any Single Procedure provided prior to the date the Enrollee became eligible for services under this plan.
(8) pain killers or experimental/investigational procedures.
(9) charges for anesthesia, other than general anesthesia and IV sedation administered by a Provider in
connection with covered oral surgery or selected endodontic and periodontal surgical procedures. Local
anesthesia(D9215) and regional/or trigeminal bloc anesthesia(D9211/D9212) are not separately payable
procedures.
(10) extraoral grafts (grafting of tissues from outside the mouth to oral tissues)(D4263, D4264).
(11) laboratory processed crowns for Enrollees under age 13(D2710, D2712, D2721, D2740, D2751, D2781,
D2783, D2791).
(12) interim implants(D6012, D6051, D6118, D6119) and endodontic endosseous implants (D3460).
(13) indirectly fabricated resin-based Inlays/Onlays(D2650 - D2664).
(14) charges by any hospital or other surgical or treatment facility and any additional fees charged by the
Provider for treatment in any such facility.
(15) treatment by someone other than a Provider or a person who by law may work under a Provider’s direct
supervision.
(16) charges incurred for oral hygiene instruction(D1330), a plaque control program, preventive control
programs including home care times, dietary instruction, x-ray duplications, cancer screening, tobacco
counseling(D1320) or broken appointments(D9986) are not separately payable procedures.
(17) dental practice administrative services including, but not limited to, preparation of claims, any non-
treatment phase of dentistry such as provision of an antiseptic environment, sterilization of equipment or
infection control, or any ancillary materials used during the routine course of providing treatment such as
cotton swabs, gauze, bibs, masks or relaxation techniques such as music.
(18) procedures having a questionable prognosis based on a dental consultant’s professional review of the
submitted documentation.
(19) any tax imposed (or incurred) by a government, state or other entity, in connection with any fees charged
for Benefits provided under the Policy, will be the responsibility of the Enrollee and not a covered Benefit.
(20) Deductibles and/or any service not covered under the dental plan.
(21) services covered under the dental plan but exceed Benefit limitations or are not in accordance with
processing policies in effect at the time the claim is processed.
(22) the initial placement of any prosthodontic appliance(D5000 – D5899, D6200 – D6999) or implant(D6000 –
D6199), unless such placement is needed to replace one or more natural, permanent teeth extracted
while the Enrollee is covered under the Policy or was covered under any dental care plan with Delta
Dental.The extraction of a third molar (wisdom tooth) will not qualify under the above. Any such denture
or fixed bridge must include the replacement of the extracted tooth or teeth.
(23) services for Orthodontic treatment (treatment of malocclusion of teeth and/or jaws) except medically
necessary Orthodontics provided a prior authorization is obtained(D8000-D8999).
(24) missed(D9986) and/or cancelled(D9987) appointments.
(25) action taken to schedule and assure compliance with patient appointments are inclusive with office
operations and are not a separately payable service.
(26) the fees for care coordination are considered inclusive in overall patient management and are not a
separately payable service.
XIAtBhi-CA-ENT-23 27
(27) dental case management motivational interviewing and patient education to improve oral health literacy.
(28) non-ionizing diagnostic procedure capable of quantifying, monitoring and recording changes in structure
of enamel, dentin, and cementum.
(29) diabetes testing.
(30) corticotomy (specialized oral surgery procedures associated with orthodontics)(D7296, D7297).
(31) Antigen or antibody testing.
XIAtChi-CA-ENT-23
Attachment C
Information Concerning Benefits for Delta Dental Individual & Family™
Delta Dental PPO™
Family Dental PPO
THIS MATRIX IS INTENDED TO BE USED TO COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE COMBINED
POLICY AND DISCLOSURE FORM SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF PLAN BENEFITS AND
LIMITATIONS.
ADULTS (AGE 19 AND OLDER)
Delta Dental PPO Providers
2
Delta Dental Premier
®
and
Non-Delta Dental Providers
2
(A) Deductibles
1
per Enrollee
$50 each Calendar Year
$50 each Calendar Year
per Family
None
None
(B) Lifetime Maximum per Enrollee
$1,500 each Calendar Year
(C) Annual Out-of-Pocket Maximum
None
(D) Professional Services
Policy Benefit Levels
Dental Service Category:
Delta Dental will pay or otherwise discharge the Policy Benefit Levels according to the Maximum
Contract Allowance for the following services:
Diagnostic and Preventive Services
100%
90%
Basic Services
80%
70%
Major Services
3
50%
50%
Medically Necessary
Orthodontic Services
Not a covered benefit Not a covered benefit
(E) Outpatient Services
Not Covered
(F) Hospitalization Services
Not Covered
(G) Emergency Dental Coverage
Benefits for Emergency Dental Services by a Non-Delta Dental
Provider are limited to necessary care to stabilize the Enrollee’s
condition and/or provide palliative relief.
(H) Ambulance Services
Not Covered
(I) Prescription Drug Coverage
Not Covered
(J) Durable Medical Equipment
Not Covered
(K) Mental Health Services
Not Covered
(L) Chemical Dependency Services
Not Covered
(M) Home Health Services
Not Covered
(N) Other
Not Covered
1
The annual Deductible is waived for Diagnostic and Preventive Services.
2
Reimbursement is based on Delta Dental PPO
Contracted Fees for Delta Dental PPO, Delta Dental Premier
and Non-
Delta Dental Providers.
3
Major Services are limited to Adult Enrollees who have been enrolled in the Policy for six consecutive months. The
six month Waiting Period for Major Services must be waived upon Enrollee’s proof of prior comparable dental
coverage. This Waiting Period shall be prorated on a one to one monthly basis upon Enrollee’s proof of prior
comparable dental coverage of less than six months. Covered California leaves it to the plan to determine acceptable
documentation to verify prior proof of coverage. Covered California leaves it to the plan to determine the maximum
allowable gap in coverage before proration of the six month Waiting Period would no longer occur. Dental services
XIAtChi-CA-ENT-23
obtained via a discount health plan are not considered “comparable” dental coverage for purposes of counting
towards the Waiting Period.
PEDIATRIC (UNDER AGE 19)
Delta Dental PPO Providers
2
Delta Dental Premier and
Non-Delta Dental Providers
2
(A) Deductibles
1
per Enrollee
$75 each Calendar Year
$75 each Calendar Year
per Family
$150 each Calendar Year
$150 each Calendar Year
(B) Lifetime Maximums per Enrollee
None
None
(C) Annual Out-of-Pocket Maximum*
Pediatric Enrollee
$350 each Calendar Year
None
Multiple Pediatric Enrollees
$700 each Calendar Year
None
(D) Professional Services
Policy Benefit Levels
Dental Service Category:
Delta Dental will pay or otherwise discharge the Policy Benefit Levels according to the Maximum
Contract Allowance for the following services:
Diagnostic and Preventive Services
100%
90%
Basic Services
80%
70%
Major Services
50%
50%
Medically Necessary
Orthodontic Services
50% 50%
(E) Outpatient Services
Not Covered
(F) Hospitalization Services
Not Covered
(G) Emergency Dental Coverage
Benefits for Emergency Dental Services by a Non-Delta Dental
Provider are limited to necessary care to stabilize the Enrollee’s
condition and/or provide palliative relief.
(H) Ambulance Services
Not Covered
(I) Prescription Drug Coverage
Not Covered
(J) Durable Medical Equipment
Not Covered
(K) Mental Health Services
Not Covered
(L) Chemical Dependency Services
Not Covered
(M) Home Health Services
Not Covered
(N) Other
Not Covered
1
The annual Deductible is waived for Diagnostic and Preventive Services.
2
Reimbursement is based on Delta Dental PPO
Contracted Fees for Delta Dental PPO, Delta Dental Premier
and Non-
Delta Dental Providers.
∗ Out-of-Pocket Maximum applies only to Essential Health Benefits that are provided by Delta Dental PPO Providers for
Pediatric Enrollees. Once the amount paid by Pediatric Enrollee(s) equals the Out-of-Pocket Maximum, no further
payment will be required by the Pediatric Enrollee(s) for the remainder of the Calendar Year for covered services
received from Delta Dental PPO Providers. Enrollee Coinsurance and other cost sharing, including balance billed
amounts, will continue to apply for covered services received from Premier and Non-Delta Dental Providers even after
the Out-of-Pocket Maximum is met.
If two or more Pediatric Enrollees are covered, the financial obligation for covered services received from Delta Dental
PPO Providers is not more than the multiple Pediatric Enrollees Out-of-Pocket Maximum. However, once a Pediatric
Enrollee meets the Out-of-Pocket Maximum for one covered Pediatric Enrollee, that Pediatric Enrollee will have
XIAtChi-CA-ENT-23
satisfied their Out-of-Pocket Maximum. Other covered Pediatric Enrollees must continue to pay Enrollee Coinsurance
for covered services received from Delta Dental PPO Providers until the total amount paid reaches the Out-of-Pocket
Maximum for multiple Pediatric Enrollees.
Can you read this document? If not, we can have somebody help you read it. You may also be able to get this document
written in your language. For free help, please call
(TTY: 711).
¿Puede leer este documento? Si no, podemos encontrar a alguien que lo ayude a leerlo. También puede obtener este
documento escrito en su idioma. Para obtener ayuda gratuita, llame al
(servicio de retransmisión TTY
deben llamar al 711). (Spanish)
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(TTY: 711)。(Chinese)
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makuha ang dokumentong ito nang nakasulat sa iyong wika. Para sa libreng tulong, pakitawagan ang
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この文書をお読みになれますか？お読みになれない場合には音読ボランティアを手配させていただきます。この文書をご希望の言
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(TTY: 711) まで お 問 い 合 わ せくだ
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Service Areas
Coverage is available in the following counties in California:
Full counties (plan
available anywhere in the
county):
Alameda
Alpine
Amador
Butte
Calaveras
Colusa
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Kings
Lake
Los Angeles
Madera
Marin
Mariposa
Mendocino
Merced
Monterey
Napa
Nevada
Orange
Placer
Plumas
Sacramento
San Benito
San Diego
San Francisco
San Joaquin
San Luis Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Solano
Sonoma
Stanislaus
Sutter
Trinity
Tulare
Ventura
Yolo
Yuba
Partial counties (plan
available only in certain
areas of the county):
Imperial
Inyo
Kern
Lassen
Modoc
Mono
Riverside
San Bernardino
Siskiyou
Tehama
Tuolumne
SA_DD_CA_22
