Clinical criteria guidelines
This guide is a general overview of what qualifies for coverage. A predetermination is recommended prior to any proposed treatment requiring clinical criteria review.
General Criteria
At Delta Dental of Washington, we take seriously our responsibility to help ensure positive treatment outcomes for our enrollees. As such, we do not allow payment for benefits when the clinical environment for the proposed or completed restorative treatment represents a poor long-term prognosis. This includes, but is not limited to, one of more of the following clinical conditions:
- Decay into a furcation, or gross decay of a crown and/or root in which insufficient sound tooth structure remains to restore a tooth
- A tooth that is fractured off, at or below the bone level, and has insufficient remaining tooth structure to restore
- Loss of supporting bone resulting in an unfavorable crown/root ratio
- Periodontal pockets of 7mm or greater
- Unexplained or untreated periapical pathology
- Obvious substandard treatment such as open margins, improper contour or inadequate occlusion on completed restorations; incomplete endodontic obturation or surgical procedures
- Root perforation
- Vertical root fracture
- Irregular tooth position (tipping or drifting) requiring excessive reduction and creating an unfavorable or traumatic occlusion on the restoration
- Clinical evidence of inadequate or neglected patient homecare and/or untreated medical conditions that compromise healing
- Untreated/unaddressed biologic width violation
Onlays, Crowns, and Veneers
- Teeth with dental caries where a significant amount of tooth structure has been destroyed by decay and can't reasonably be treated with a direct restoration
- Teeth with fractured off/broken off tooth structure not replaced with an existing restoration and can't reasonably be treated with a direct restoration. Note: Restorations for altering occlusion and/or vertical dimension, or replacing tooth structure lost by attrition, erosion, abrasion (wear) are not a contract benefit.
- Teeth with a fractured or broken existing restoration that can't reasonably be replaced with a direct restoration
- Endodontically treated posterior teeth without an existing restorative crown. Note: Endodontic treatment by itself in an anterior tooth is not a qualifying condition for crown payment. An anterior tooth must also meet the clinical criteria stated above to allow payment.
- Confirmed diagnosis of cracked tooth syndrome on posterior teeth. For an onlay or crown to be considered for coverage due to cracked tooth syndrome, we require specific information in the chart notes documenting the type of clinical diagnostic testing used, the cusp(s) involved and any other signs and symptoms associated with the tooth. Note: A restoration placed due to cracks, fracture lines or craze lines without actual displacement of tooth structure is not a contract benefit.
- Teeth with existing indirect restorations with new pathology such as decay, fractured off tooth structure or fracture of the existing restorative material
Dental Consultant Tip: A copy of the chart notes documenting a tooth-specific diagnosis, and labeled and dated diagnostic image(s) are helpful for clinical review of a claim. If qualifying pathology is not self-evident on the radiographs, providing a copy of labeled and dated intra-oral photo(s) can help expedite the review of a claim.
Clinical Crown Lengthening (D4249)
This procedure is done to facilitate the placement of a restoration when the biological width has been compromised.
Requirements:
- Procedure is performed in a healthy periodontal environment
- Crown lengthening is needed to gain access for placement of a direct or indirect restoration due to qualifying pathology (decay or broken off tooth structure).
- Full thickness flap
- Removal of supporting bone, altering the crown to root ratio
- Adequate healing period of 4-6 weeks between the crown lengthening surgery and the impression taken for an indirect restoration
Documentation:
- Current diagnostic image(s)
- Diagnosis and rationale for performing clinical crown lengthening to include the proposed follow-on restorative treatment plan
- Periodontal condition of the tooth
Dental Consultant Tip: Clinical Crown lengthening is payable per site, not per tooth, when the surgery includes adjacent teeth.
Core Buildups
- A core buildup is allowed for a posterior tooth when one cusp is missing down to, or closer than, 2mm from the gum tissue in preparation for a restorative crown. A core buildup is allowed for an anterior tooth when more than ½ of the mesial-distal width of the incisal edge is missing down past the junction of the incisal and middle third of the tooth.
- Buildups are covered on endodontically treated anterior teeth without an existing crown only if the above criteria are met.
- Buildups are routinely covered on posterior endodontically treated teeth without an existing restorative crown.
- A buildup is not an additional benefit with placement of an onlay, 3/4 crown or veneer.
- Buildups are not a benefit if the tooth does not meet clinical criteria for a crown.
Dental Consultant Tip: A copy of the chart notes documenting a tooth-specific diagnosis, and labeled and dated diagnostic image(s) are helpful for clinical review of a claim. If qualifying pathology is not self-evident from the radiographs, providing a copy of labeled and dated, pre-op and/or intra-op photo(s) can help expedite the review of a claim.
Scaling and Root Planing (D4341/D4342)
This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients diagnosed with periodontal disease and is therapeutic, not prophylactic, in nature.
- A periodontal chart is required with readings for the treated quadrant(s) dated no more than 12 months prior to the date of treatment.
- Current, dated, diagnostic-quality images are required. A panoramic radiograph alone has limited value in diagnosing periodontal disease and is not acceptable for clinical review of a benefit claim for periodontal scaling and root planing.
Dental Consultant Tip: To meet the required clinical criteria for periodontal scaling and root planning, the following must be evident:
- Radiographic evidence of bone loss in the treated quadrant(s). The root cannot be accessed for planing if there is no bone loss. Pseudo-pocketing can result from gingival inflammation, and treatment of this condition should be submitted as a prophylaxis or D4346, depending on the extent and severity of gingivitis.
- For patients age 19 and under the following documentation is required: a copy of the chart notes, dated diagnostic-quality images, and a periodontal chart documenting probing depths and any furcation involvement and/or areas of recession recorded within 12 months of date of service.
- Special consideration is only given to three or four quadrants of SRP when reported on the same date of service when a claim includes: a current periodontal chart (recorded within the past 12 months); current, dated and diagnostic-quality images; and chart notes detailing the diagnosis, special circumstances of the treatment and the length of appointment.
Surgical Periodontal services
Benefits for surgical periodontal services are determined based on the number of qualifying teeth in the quadrant. Qualifying teeth must have at least one 5mm (or greater) pocket depth reading. For some groups, teeth adjacent to a mesial or distal 5mm (or greater) pocket depth reading are also considered to be qualifying teeth.
- Some groups require supportive therapy. Periodontal supportive therapy is defined as either periodontal root planing and scaling (D4341/D4342) or periodontal maintenance (D4910) completed no less than six weeks and no more than six months prior to the date of surgery. Procedure codes that may require supportive therapy include but not limited to: Gingival flap procedure (D4240, D4241) and osseous surgery (D4260, D4261); and localized delivery of antimicrobial agents (D4381).
Surgical Extractions
- D7210 extraction of an erupted tooth requiring removal of bone and/or sectioning of tooth, including elevation of mucoperiosteal flap, if indicated. Elevation of a flap without bone removal or tooth sectioning is not a D7210 procedure. D7210 includes cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and closure
- D7220 should be reported when the tooth is not erupted to the occlusal plane and has soft tissue covering the occlusal surface of the tooth; requires mucoperiosteal flap elevation
- D7230 should be reported when part of the crown is covered by bone above the height of contour and the tooth is clearly below the occlusal plane; requires mucoperiosteal flap elevation and bone removal
- D7240 should be reported when most or all the crown is covered by bone above the height of contour and the tooth is clearly below the occlusal plane; requires mucoperiosteal flap elevation and bone removal
D7241 should be reported only when the tooth meets all the criteria for D7240 and the extraction was unusually complicated due to factors such as the examples below. Requires a current pre-operative diagnostic radiograph and, in some cases, a copy of the operation notes may be requested by clinical review.
- The tooth is ankylosed
- Nerve dissection is required
- Separate closure of maxillary sinus is required
- The tooth is in a significantly aberrant position
- Horizontal impaction facing buccal/lingual (more than 45° from the arch form)
- More than one-fourth of the roots and/or the crown of the tooth below the inferior alveolar nerve
- Disto-angular impaction with dilacerated roots curving distally
- Vertical impaction with the occlusal surface of the tooth at the level of the apical one-third or higher of the adjacent tooth
D7250 should be reported for removal of unexposed residual roots requiring cutting of soft tissue and bone for access. If a root is exposed and can be removed with an elevator or curette, it should be reported as D7140. If exposed roots require sectioning and bone removal, the surgery should be reported as D7210. D7250 may also be reported for unexposed residual tooth roots left behind by another provider at a previous extraction visit.
Dental Consultant Tips
- Ensure the radiographs submitted with a claim are diagnostic-quality and clearly show the roots and positioning of the tooth/teeth in question
- Include operation notes when reporting an extraction D7210 through D7241 - especially when the images do not reflect the complexity of the procedures performed
- If the removal of a supernumerary tooth is performed in the same surgical site as a permanent tooth extraction, payment is allowed at half of the approved fee for the supernumerary tooth in accordance with a group's co-pay level
- D7140 should be reported any time an erupted tooth or an exposed, retained root is extracted by elevation (elevators and periotomes) and/or forceps delivery
Medical Necessity Policy for Orthodontia
Certain plans require orthodontic treatment be preauthorized and all care completed by an orthodontist. Benefit coverage for orthodontic treatment and orthodontic-related services for a patient who has a severe malocclusion and associated with one of the following medical conditions:
- Cleft lip and palate, cleft palate, or cleft lip with alveolar process involvement, or
- Medical conditions as indicated on the Washington Modified Handicapping Labiolingual Deviation (HLD) Index Score that result in a score of 25 or higher or
- The following craniofacial anomalies: Hemifacial Microsomia, Craniosynostosis syndromes, Cleidocranial dysplasia, Arthogryposis, or Marfan syndrome.
Lost or broken orthodontic appliances, orthodontic treatment for cosmetic purposes, orthodontic treatment that is not medically necessary, orthodontic treatment received outside the state of Washington, and orthodontic treatment that is not preauthorized are not covered benefits.
Request for preauthorization of orthodontic treatment must include the Delta Dental Orthodontic Form for Medical Necessity and a full series of orthodontic photographs to include three extraoral and five intraoral images, including occlusal views. Photographs should be consistent with the standards of the American Board of Orthodontics and of sufficient quality to demonstrate the medical condition. Poor quality photographs that fail to demonstrate the medical condition will result in any benefit claim being made not billable to the patient. Radiographs are not required, but if necessary to demonstrate a HLD score of medical necessity should be submitted with the Delta Dental Orthodontic Form for Medical Necessity and the photographs.
Medically necessary occlusal orthotics do not require a separate preauthorization but will only be covered if there is an approved preauthorization for medically necessary orthodontics on file.
