2
018  
Clinical Criteria, Guidelines  
and Practice Parameters  
CLINICAL DENTISTRY GUIDELINES
PREFACE  
LIBERTY Dental Plan’s Clinical Criteria Guidelines and Practice Parameters were originally developed in 2005 and are  
subject to periodic revisions and annual review by the QMI Committee and Board of Directors. The criteria document  
was developed internally by our Dental Directors with input from participating panel general dentists and specialists.  
LIBERTY utilizes the American Dental Association’s “Dental Practice Parameters,” sound dental clinical principles,  
processes and evidence to consistently evaluate the appropriateness of dental services that require review.  
LIBERTY Dental Plan Executive Approval  
The LIBERTY Dental Plan Quality Management and Improvement Committee has reviewed and approved the Clinical  
Criteria, Guidelines and Practice Parameters.  
1
2/12/2017  
Dental Director/QMI Chair  
Date  
LIBERTY Dental Plan’s Board of Directors has reviewed and approved the Clinical Criteria, Guidelines and Practice  
Parameters as proposed by the Quality Management Committee.  
1
2/12/2017  
Executive Vice President/Board Representative  
Date  
Please note that specific Plan/Program guidelines supersede the information contained in LIBERTY’s Clinical Criteria  
Guidelines and Practice Parameters document.  
Clinical Criteria Guidelines v.20180109  
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CLINICAL DENTISTRY GUIDELINES
TABLE OF CONTENTS  
NEW PATIENT INFORMATION.................................................................................................................................................4  
CLINICAL ORAL EVALUATIONS ................................................................................................................................................4  
INFORMED CONSENT ……………………………………………………………………………………………………………………………………………………… 5  
PRE‐DIAGNOSTIC SERVICES.....................................................................................................................................................5  
DIAGNOSTIC IMAGING............................................................................................................................................................5  
TESTS, EXAMINATIONS AND REPORTS....................................................................................................................................6  
PREVENTIVE TREATMENT .......................................................................................................................................................6  
RESTORATIVE TREATMENT .....................................................................................................................................................7  
ENDODONTICS ........................................................................................................................................................................9  
PERIODONTICS....................................................................................................................................................................111  
REMOVABLE PROSTHETICS ...................................................................................................................................................16  
ORAL SURGERY......................................................................................................................................................................18  
ADJUNCTIVE SERVICES..........................................................................................................................................................19  
RETROSPECTIVE REVIEW.....................................................................................................................................................221  
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CLINICAL DENTISTRY GUIDELINES
NEW PATIENT INFORMATION  
A. Registration information should include:  
1
. Name, sex, birth date, address and telephone number, cell phone number, e‐mail address, name of employer,  
work address and telephone number, language of preference.  
2
3
4
. Name and telephone number of person(s) to contact in an emergency.  
. For minors, name of parent(s) or guardian(s) and telephone numbers, if different from above.  
. Pertinent information relative to the patient’s chief complaint and dental history, including any problems or  
complications with previous dental treatment, previous dentist/dental clinic and date of last dental examination.  
. Medical History ‐ There should be a detailed medical history form comprised of questions which require a “Yes”  
or “No” response, including:  
5
a. Patient’s current health status  
b. Name and telephone number of physician and date of last visit  
c. History of hospitalizations and/or surgeries  
d. Current medications, including dosages and indications  
e. History of drug and medication use (including Fen‐Phen/Redux and bisphosfonates)  
f. Allergies and sensitivity to medications (including antibiotics) or materials (including latex)  
g. Adverse reaction to local anesthetics  
h. History of diseases or conditions:  
i.  
Cardio‐vascular disease, including history of abnormal (high or low) blood pressure, heart attack,  
stroke, history of rheumatic fever or heart murmur, existence of pacemakers, valve replacements  
and/or stents and bleeding problems, etc.  
ii.  
iii.  
Pulmonary disorders including COPD, tuberculosis, asthma and emphysema  
Nervous disorders, including psychiatric treatment  
iv.  
v.  
vi.  
Diabetes, endocrine disorders, and thyroid abnormalities  
Liver or kidney disease, including hepatitis and kidney dialysis  
Sexually transmitted diseases  
vii.  
viii.  
Disorders of the immune system, including HIV status/AIDS  
Other viral diseases  
ix.  
x.  
Musculoskeletal system, including prosthetic joints and when they were placed  
History of cancer, including radiation or chemotherapy  
6
. Pregnancy  
a. Document the name of the patient’s obstetrician and estimated due date.  
b. Follow current guidelines in the ADA publication, Women’s Oral Health Issues.  
7
8
. The medical history form must be signed and dated by the patient or patient’s parent or guardian.  
. Dentist’s notes following up patient comments, significant medical issues and/or consultation with a physician  
should be documented on the medical history form or in the progress notes.  
9
. Medical alerts for significant medical conditions must be uniform and conspicuously located on the monitor for  
paperless records or on a portion of the chart used and visible during treatment and should reflect current  
conditions.  
1
1
0. The dentist must sign and date all baseline medical histories after review with the patient. If electronic dental  
records are used, indication in the progress notes that the medical history was reviewed is acceptable.  
1. The medical history should be updated at appropriate intervals, dictated by the patient’s history and risk factors,  
and must be documented at least annually and signed by the patient and dentist.  
CLINICAL ORAL EVALUATIONS  
A. Periodic oral evaluations (Code D0120) of an established patient may only be provided for a patient of record who  
has had a prior comprehensive examination. Periodontal evaluations and oral cancer screenings should be updated  
at appropriate intervals, dictated by the patient’s history and risk factors, and should be done at least annually.  
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CLINICAL DENTISTRY GUIDELINES
B. A problem‐focused limited examination (Code D0140) must document the issue substantiating the medical necessity  
of the examination and treatment. (MM014)  
C. An oral evaluation of a patient less than seven years of age should include documentation of the oral and physical  
health history, evaluation of caries susceptibility and development of an oral health regimen.  
D. A comprehensive oral evaluation for new or established patients (Code D0150) who have been absent from active  
treatment for at least three years or have had a significant change in health conditions should include the following:  
1
. Observations of the initial evaluation are to be recorded in writing and charted graphically where appropriate,  
including missing or impacted teeth, existing restorations, prior endodontic treatment, fixed and removable  
appliances.  
2
3
. Assessment of TMJ status (necessary for adults) and/or classification of occlusion (necessary for minors) should  
be documented.  
. Full mouth periodontal screening must be documented for all patients; for those patients with an indication of  
periodontal disease, probing and diagnosis must be documented, including a radiographic evaluation of bone  
levels, gingival recession, inflammation, etiologic factors (e.g., plaque and calculus), mobility, and furcation  
involvements.  
4
. A soft tissue/oral cancer examination of the lips, cheeks, tongue, gingiva, oral mucosal membranes, pharynx and  
floor of the mouth must be documented for all patients, regardless of age.  
E. A post‐operative office visit for re‐evaluation should document the patient’s response to the prior treatment.  
MM014)  
(
INFORMED CONSENT  
A. The dentist should have the member sign appropriate informed consent documents and financial agreements.  
B. Following an appropriate informed consent process, if a patient elects to proceed with a procedure that is not  
covered, the member is responsible for the dentist’s usual fee.  
PRE‐DIAGNOSTIC SERVICES  
A. Screening of a patient, which includes a state or federal mandate, is used to determine the patient’s need to see a  
dentist for diagnosis.  
B. Assessment of a patient is performed to identify signs of oral or systemic disease, malformation or injury and the  
potential need for diagnosis and treatment.  
DIAGNOSTIC IMAGING  
Based on the dentist’s determination that there is generalized oral disease or a history of extensive dental treatment, an  
adequate number of images should be taken to make an appropriate diagnosis and treatment plan, per current  
FDA/ADA radiographic guidelines to minimize the patient's exposure. Photographic images may also be needed to  
evaluate and/or document the existence of pathology.  
A. An attempt should be made to obtain any recent radiographic images from the previous dentist.  
B. An adequate number of initial radiographic images should be taken to make an appropriate diagnosis and treatment  
plan, per current FDA/ADA radiographic guidelines. This includes the ALARA Principle (As Low As Reasonably  
Achievable) to minimize the patient’s exposure. It is important to limit the number of radiographic images obtained  
to the minimum necessary to obtain essential diagnostic information. (MM020)  
C. The patient should be evaluated by the dentist to determine the radiographic images necessary for the examination  
prior to any radiographic survey.  
D. Intraoral – complete series (including bitewings) (Code D0210)  
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CLINICAL DENTISTRY GUIDELINES
Note: D0210 is a radiographic survey of the whole mouth, usually consisting of 14‐22 periapical and posterior bitewing  
images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone.  
1
2
. Benefits for this procedure are determined within each plan design.  
. Any benefits for periapical and/or bitewing radiographs taken on the same date of service will be limited to a  
maximum reimbursement of the provider’s fee for a complete series.  
3
4
. Any panoramic film taken in conjunction with periapical and/or bitewing radiograph(s) will be considered as a  
complete series, for benefit purposes only.  
. Decisions about the types of recall films should also be made by the dentist and based on current FDA/ADA  
radiographic guidelines, including the complexity of previous and proposed care, caries, periodontal  
susceptibility, types of procedures and time since the patient’s last radiographic examination.  
E. Diagnostic radiographs should reveal contact areas without cone cuts or overlapping, and periapical films should  
reveal periapical areas and alveolar bone.  
F. Radiographs should exhibit good contrast.  
G. Diagnostic digital radiographs should be submitted electronically when possible or should be printed on  
photographic quality paper and exhibit good clarity and brightness.  
H. All radiographs must be mounted, labeled left/right and dated.  
I. Intra or extra‐oral photographic images should only be taken to diagnose a condition or demonstrate a need for  
treatment that is not adequately visualized radiographically. (MM0350)  
J. Any patient refusal of radiographs should be documented.  
K. Radiograph duplication fees:  
1
2
. Radiographic image duplication fees are not allowed.  
. When a patient is transferred from one contracted provider to another, diagnostic copies of all radiographic  
images less than two years old should be duplicated for the second provider.  
L. Diagnostic casts (Code D0470) are only considered medically necessary as an aid for treatment planning specific oral  
conditions. (MM047)  
TESTS, EXAMINATIONS AND REPORTS  
A. Tests, examinations and reports may be required when medically necessary to determine a diagnosis or treatment  
plan for an existing or suspected oral condition or pathology. (MM041, MM047)  
B. Oral pathology laboratory procedure/report may be required when there is evidence of a possible oral pathology  
problem. (MM0472).  
PREVENTIVE TREATMENT  
A. Dental prophylaxis (Code D1110 and D1120) may be medically necessary when documentation shows that there is  
evidence of plaque, calculus or stains on tooth structures. (MM111)  
B. Topical fluoride (Codes D1206 and D1208) treatment may be medically necessary when documentation shows that  
there is evidence of the need for this preventive procedure. (MM120)  
C. A sealant (Code D1351) or preventive resin restoration (Code D1352) may be medically necessary to prevent decay  
in a pit or fissure or as a conservative restoration in a cavitated lesion that has not extended into dentin on a  
permanent tooth in a moderate to high caries risk patient. (MM135)  
D. A space maintainer (Codes D1510 – D1525) may be medically necessary to prevent tooth movement and/or  
facilitate the future eruption of a permanent tooth. (MM150)  
E. Recognizing medical conditions that may contribute to or precipitate the need for additional prophylaxis  
procedures, supported by the patient’s physician. Verify plan benefits prior to performing additional prophylaxis  
procedures in excess of plan limitations.  
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CLINICAL DENTISTRY GUIDELINES
F. Interim caries arresting medicament application (Code D1354) Silver Diamine Fluoride (SDF) is an interim caries  
arresting liquid medicament clinically applied to control and prevent the further progression of active dental caries,  
and reduce dental hypersensitivity. Treatment with Silver Diamine Fluoride will not eliminate the need for  
restorative dentistry to repair function or aesthetics, but this alternative treatment allows oral health care  
professionals to temporarily arrest caries with noninvasive methods, particularly with young children that have  
primary teeth. This should be submitted on a per tooth basis.  
RESTORATIVE TREATMENT  
A. Restorative procedures for teeth exhibiting a poor prognosis due to gross carious destruction of the clinical crown  
at/or below the bone level, advanced periodontal disease, untreated periapical pathology or poor restorability are  
not covered. (MMPROG_) (MMPROGR)  
B. Amalgam Restorations (Codes D2140‐D2161)  
1
. Dental amalgam is a cavity‐filling material made by combining mercury with other metals such as silver, copper  
and tin. Numerous scientific studies conducted over the past several decades, including two large clinical trials  
published in the April 2006 Journal of the American Medical Association, indicate dental amalgam is a safe,  
effective cavity‐filling material for children and others. And, in its 2009 review of the scientific literature on  
amalgam safety, the ADA's Council on Scientific Affairs reaffirmed that the scientific evidence continues to  
support amalgam as a valuable, viable and safe choice for dental patients…”  
2
. On July 28, 2009, the American Dental Association (ADA) agreed with the U.S. Food and Drug Administration's  
(FDA) decision not to place any restriction on the use of dental amalgam, a commonly used cavity filling  
material:  
a. The procedures of choice for treating caries or the replacement of an existing restoration not involving or  
undermining the cusps of posterior teeth is generally amalgam or composite.  
b. Facial or buccal restorations are generally considered to be “one surface” restorations, not three surfaces  
such as MFD or MBD. (MMMOD)  
c. The replacement of clinically acceptable amalgam fillings with an alternative material (composite, crown,  
etc.) is considered cosmetic and is not covered unless decay or fracture of the existing filling is present.  
(MMTRT)  
d. If a dentist chooses not to provide amalgam fillings, alternative posterior fillings must be made available for  
LIBERTY patients. Any listed amalgam copayments would still apply.  
e. An amalgam restoration includes tooth preparation and all adhesives, liners and bases. (MMINC)  
f. An amalgam restoration may be medically necessary when a tooth has a fracture, defective filling or decay  
penetrating into the dentin. (MM214)  
g. An amalgam restoration should have sound margins, appropriate occlusion and contacts and must treat all  
decay that is evident. (MM241)  
C. Resin‐based Composite Restorations (Codes D2330 – D2394)  
1
. The procedures of choice for treating caries or the replacement of an existing restoration not involving or  
undermining the incisal edges of an anterior tooth is composite. Decay limited to the incisal edge only, may still  
be a candidate for a filling restoration if little to no other surfaces manifest caries or breakdown.  
. Facial or buccal restorations are generally considered to be “one surface” restorations, not three surfaces such  
as MFD or MBD. (MMMOD)  
. The replacement of clinically acceptable amalgam fillings with alternative materials (composite, crown, etc.) is  
considered cosmetic and is not covered unless decay or fracture is present. (MMTRT)  
. A resin‐based composite restoration includes tooth preparation, acid etching, adhesives, liners, bases and  
curing. (MMINC)  
. A resin‐based composite restoration may be medically necessary when a tooth has a fracture, defective filling,  
recurrent decay or decay penetrating into the dentin. (MM230) (MM231)  
. A composite restoration should have sound margins, appropriate occlusion and contacts and must treat all  
decay that is evident. (MM232)  
2
3
4
5
6
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CLINICAL DENTISTRY GUIDELINES
7
. If LIBERTY determines that there is a more appropriate procedure code to describe the restoration provided,  
either number of surfaces, or material used, an alternate procedure code may be approved. (MM230M)  
(
MM232M) (MM240M) (MM241M)  
D. Restorations for primary teeth are covered only if the tooth is symptomatic, proximal to permanent teeth, or  
expected to be present for six months or longer. (MM290)  
E. For posterior primary teeth that have had extensive loss of tooth structure or when it is necessary for preventive  
reasons, the appropriate treatment is generally a prefabricated stainless steel crown or for anterior teeth, a stainless  
steel or prefabricated resin crown.  
F. A resin infiltration of an incipient smooth surface lesion (decalcification) is appropriate for smooth surface lesions  
with some or minor enameloplasty. (MM2990)  
G. Crowns ‐ Single Restorations Only (Codes D2712 – D2791)  
1
. Administrative Issues  
a. Providers may document the date of service for these procedures to be the date when final impressions are  
completed (subject to review).  
b. Providers must complete any irreversible procedure started regardless of payment or coverage and only bill  
for indirect restorations when the service is completed (permanently cemented).  
c. Crown services must be documented using valid procedure codes in the American Dental Association’s  
Current Dental Terminology (CDT).  
2
. A crown may be medically necessary when the tooth is present and:  
a. The tooth has evidence of decay undermining more than 50% of the tooth (making the tooth weak), when a  
significant fracture is identified, or when a significant portion of the tooth has broken or is missing and has  
good endodontic, periodontal and/or restorative prognoses (MM272) (MM273) (MM237R) (MM274)  
(
(
MM274E) (MM275) (MM275P) and is not required due to wear from attrition, abrasion and/or erosion  
MM2LIM).  
b. There is a significantly defective crown (defective margins or marginal decay) or there is recurrent decay.  
MM270)  
(
c. The tooth is in functional occlusion. (MM271)  
d. When anterior teeth have incisal edges/corners that are undermined or missing because of caries, a  
defective restoration or are fractured off, a labial veneer may not be sufficient. The treatment of choice may  
be a porcelain fused to base metal crown or a porcelain/ceramic substrate crown. (MM296)  
e. The tooth has a good endodontic, periodontic and restorative prognosis with a minimum crown/root ratio of  
50% and a life expectancy of at least five years. (MMPROG_)  
3
. Enamel “craze” lines or “imminent” or “possible” fractures: Anterior or posterior teeth that show a discolored  
line in the enamel indicating a non‐decayed defect in the surface enamel and are not a through‐and through  
fracture should be monitored for future changes. Crowns may be a benefit only when there is evidence of true  
decay undermining more than 50% of the remaining enamel surface, or when there is a through‐and‐through  
fracture identified radiographically or photographically, or when a portion of the tooth has actually fractured off  
and is missing. Otherwise, there is no benefit provided for crown coverage of a tooth due to a “suspected future  
or possible” fracture. (MM272)  
4
5
. Final crowns for teeth with a good prognosis should be sequenced after performing necessary endodontic  
and/or periodontal procedures and such teeth should exhibit a minimum crown/root ratio of 50%.  
. Types of Crowns  
a. When bicuspid and anterior crowns are covered, the benefit is generally porcelain fused to a base metal  
crown or a porcelain/ceramic substrate crown.  
b. When molar crowns are indicated due to caries, an undermined or fractured cusp or the necessary  
replacement of a restoration due to pathology, the benefit is usually a base metal crown.  
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CLINICAL DENTISTRY GUIDELINES
c. Porcelain/ceramic substrate crowns and porcelain fused to metal crowns on molars may be susceptible to  
fracture during occlusal function. Depending on the properties of the material used, it may not be  
consistent with good clinical practice to routinely use all‐porcelain/ceramic restorations on molar teeth.  
d. Stainless steel crowns (Codes D2930 – D2933) are primarily used on deciduous teeth and only used on adult  
teeth due to a patient’s disability/inability to withstand typical crown preparation.  
6
. Crown and Bridge Unit Upgrades  
a. Plan designs limit the total maximum amount chargeable to a member for any combination of upgrades to  
$
250 per unit.  
b. Typical upgrades include:  
i. Choice of metal – noble, high noble  
ii. Porcelain on molar teeth  
iii. Based on the particular plan design, porcelain margins may be charged separately. A reasonable amount  
may be charged ($100 or less per unit). A patient signed informed consent accepting the optional nature  
and charge for this feature must be present.  
iv. Grievances involving charges for upgrades will be found in favor of the Provider’s right to charge for  
upgraded features only when a signed informed consent or treatment plan is present that meets the  
“prudent layperson” requirement for clear disclosure of the proposed upgraded features, including risks,  
benefits and alternatives. Members must have an option to access to their covered benefit as well as any  
upgraded procedures.  
. Core Buildup, including any pins when required (Code D2950), must show evidence that the tooth requires  
additional structure to support and retain a crown. (MM291)  
7
8
a. Core buildup refers to building up of coronal structure when there is insufficient retention for an extra‐  
coronal restorative procedure.  
b. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation.  
. Post and core (Code D2952 and D2954) procedures for endodontically treated teeth include buildups. By CDT  
definitions, each of these procedures includes a “core.” Therefore, a core buildup, cannot be billed with either  
Codes D2952 or D2954 for the same tooth, during the same course of treatment. (MMINC)  
a. The tooth is functional, has had root canal treatment and the tooth requires additional structure to support  
and retain a crown. (MM295) (MM299)  
b. Post and core in addition to crown (Code D2952), is an indirectly fabricated post and core custom fabricated  
as a single unit.  
c. Prefabricated post and core in addition to crown (Code D2954) is built around a prefabricated post. This  
procedure includes the core material.  
. Pin retention or restorative foundation may be medically necessary when a tooth requires a foundation for a  
restoration. (MM2951)  
0. A coping (Code D2975) or crown under a partial denture may be required when submitted documentation  
demonstrates the medical necessity of the procedure. (MM297)  
1. Repair of a restorative material failure may be medically necessary when submitted documentation establishes  
restorative material failure. (MM298)  
9
1
1
1
2. Outcomes: Standards set by the specialty boards shall apply.  
a. Margins, contours, contacts and occlusion must be clinically acceptable.  
b. Tooth preparation should provide adequate retention and not infringe on the dental pulp.  
c. Crowns should be designed with a minimum life expectancy or service life of five years.  
ENDODONTICS  
A. Assessment  
1
. Diagnostic techniques used when considering possible endodontic procedures may include an evaluation of:  
a. Pain and the stimuli that produce or relieve it by the following tests:  
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i. Thermal  
ii. Electric  
iii. Percussion  
iv. Palpation  
v. Mobility  
b. Non‐symptomatic radiographic lesions  
B. Treatment planning for endodontic procedures may include consideration of the following:  
1
2
. Strategic importance of the tooth or teeth  
. Prognosis – endodontic procedures for teeth with a guarded or poor 5‐year prognosis (endodontic, periodontal  
or restorative) are not covered (MMPROG)  
a. Excessively curved or calcified canals  
b. Presence and severity of periodontal disease  
c. Restorability and tooth fractures  
3
4
. Occlusion  
. Teeth that are predisposed to fracture following endodontic treatment should be protected with an appropriate  
restoration; most posterior teeth should be restored with a full coverage restoration.  
C. Clinical Guidelines  
1
2
3
4
. Diagnostic pre‐operative radiographs of teeth to be endodontically treated must reveal all periapical areas and  
alveolar bone.  
. A rubber dam should be used and documented (via radiograph or in the progress notes) for most endodontic  
procedures. Documentation is required for any inability to use a rubber dam.  
. Gutta percha is the endodontic filling material of choice and should be densely packed and sealed. All canals  
should be completely obturated.  
. Post‐operative radiograph(s), showing all canals and apices, must be taken immediately after completion of  
endodontic treatment.  
5
6
. In the absence of symptoms, post‐operative radiographs should be taken at appropriate periodic intervals.  
. For direct or indirect pulp caps, documentation is required that shows a direct or near exposure of the pulp.  
Direct or indirect pulp cap procedures are not considered bases and liners. (MM310)  
a. Direct pulp capping is indicated for mechanical or accidental pulp exposures in relatively young teeth and  
may be indicated in the presence of a small, exposed vital or normal pulp.  
b. Indirect pulp capping (re‐mineralization) is indicated to attempt to minimize the possibility of pulp exposure  
in very deep caries in vital teeth.  
7
8
. For a pulpotomy (Code D3220) or pulpal therapy (Codes D3230 and D3240), documentation is required that  
shows pulpal pathology and a good prognosis that the tooth has a reasonable period of retention and function.  
(
MM320) (MM232)  
. For endodontic treatment (Codes D3310 – D3330), documentation is required that shows the treatment is  
medically necessary (i.e., tooth is broken, decayed or previously restored, functional with an unhealthy nerve  
and more than 50% of the tooth structure is sound) and the tooth has a good endodontic, periodontal and/or  
restorative prognosis. (MM330) (MM300) (MM331E) (MM331P) (MM331R)  
Note: LIBERTY may determine that a different, more appropriate procedure code better describes the endodontic  
treatment performed and may make our determination based on the alternate code (MM330M)  
9
1
. For apexification/recalcification (Codes D3351 – D3353), documentation is required that shows the apex of the  
tooth root(s) is/are incompletely developed. (MM335)  
0. For apical surgery (Codes D3410 – D3426), documentation is required that shows apical or lateral pathosis that  
cannot be treated non‐surgically and that the tooth has a good periodontal (MM340P) and restorative  
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(
MM340R) prognosis. (MM340) Endodontic apical surgical treatment should be considered only in specific  
circumstances, including:  
a. The root canal system cannot be instrumented and treated non‐surgically.  
b. There is active root resorption.  
c. Access to the canal is obstructed.  
d. There is gross over‐extension of the root canal filling.  
e. Periapical or lateral pathosis persists and cannot be treated non‐surgically.  
f. Root fracture is present or strongly suspected.  
g. Restorative considerations make conventional endodontic treatment difficult or impossible.  
Note: LIBERTY may determine that the apical surgery requested could have a better/equivalent outcome with a different  
endodontic procedure code (MM340M)  
1
1
1
1. For a retrograde filling (Code D3430), documentation is required that shows evidence of medical necessity for a  
retrograde filling during periradicular surgery. (MM3430)  
2. For a surgical or endodontic implant procedure (Code D3460), documentation is required that shows evidence  
of medical necessity for the procedure. (MM345)  
3. Endodontic irrigation  
a. Providers are contractually obligated to not charge more than the listed copayment for covered root canal  
procedures whether the dentist uses BioPure, diluted bleach, saline, sterile water, local anesthetic and/or  
any other acceptable alternative to irrigate the canal. (MMINC)  
b. Providers may not unbundle dental procedures to increase reimbursement from LIBERTY or enrollees. The  
provider agreement and plan addenda determine what enrollees are to be charged for covered dental  
procedures. BioPure as an alternative allowed on LIBERTY dental plans at no additional cost, whether or not  
a choice is presented to the Member.  
PERIODONTICS  
A. Evaluations  
1
2
3
. All children, adolescents and adults should be evaluated for evidence of periodontal disease. If pocket depths do  
not exceed 3 mm and there is no bleeding on probing or evidence of radiographic bone loss, it is appropriate to  
document the patient’s periodontal status as being “within normal limits” (WNL).  
. In many cases a periodontal screening activity such as visual inspection, PSR® (Periodontal Screening and  
Recording) evaluation of each sextant or other mechanism may provide sufficient information to make a  
diagnosis or treatment plan.  
. Comprehensive oral evaluations should include the following:  
a. Quality and quantity of gingival tissue  
b. Documentation: six‐point periodontal probing for each tooth  
c. The location of bleeding, exudate, plaque and/or calculus  
d. Significant areas of recession, mucogingival problems, level and amount of attached gingiva  
e. Mobility  
f. Open or improper contacts  
g. Furcation involvement  
h. Occlusal contacts or interferences  
4
5
. After a comprehensive evaluation, a diagnosis and treatment plan should be completed.  
. Sequential charting over time to show changes in periodontal architecture is of considerable value in  
determining treatment needed or to evaluate the outcome of previous treatment.  
B. Periodontal treatment sequencing  
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1
. Full mouth debridement to enable comprehensive evaluation and diagnosis (Code D4355) is “The gross removal  
of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation.  
This preliminary procedure does not preclude the need for additional procedures.” (CDT)(MM430)  
a. In most cases, this procedure would be followed by the completion of a comprehensive evaluation at a  
subsequent appointment. This rescheduling may allow some initial soft tissue response and shrinkage prior  
to performing full mouth periodontal probing.  
b. This procedure must be supported by radiographic or photographic evidence of heavy calculus, is not a  
replacement code for a prophylaxis and is not appropriate on the same day as procedure comprehensive  
oral evaluation or a comprehensive periodontal evaluation (codes D0150 or D0180). (MM430)  
. Scaling in the presence of generalized moderate or severe gingival inflammation (Code D4346) is "The removal  
of plaque, calculus and stains from supra‐ and sub‐gingival tooth surfaces when there is generalized moderate or  
severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen,  
inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. It should not be  
reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures." (MM4346)  
a. This procedure is for generalized moderate to severe gingival inflammation.  
2
b. The ADA suggests that "generalized" would apply when 30% or more of the patient's teeth at one or more  
sites are involved, which is analogous to the AAP definition of generalized chronic periodontitis.  
c. The Loe & Silness Gingival Index can be a guideline for defining "moderate to severe inflammation"  
i.  
ii.  
iii.  
iv.  
v.  
vi.  
vii.  
viii.  
ix.  
Moderate inflammation ‐ redness, edema, glazing; bleeding on probing  
Severe inflammation ‐ marked redness and edema, ulceration; tendency toward spontaneous bleeding  
This is a therapeutic procedure, to treat a diagnosed disease.  
It is based on a diagnosis, not on intensity of treatment required.  
It is appropriate for patients who do not have periodontitis (i.e. attachment loss).  
It is performed after a periodic or comprehensive exam.  
It can be performed on same date of service as the exam.  
It is a full mouth procedure, not a per quadrant procedure.  
Can be used for any age patient, and in any dentition stage (note that benefits vary by each member’s  
plan design).  
x.  
"...in conjunction with..." means on the same date of service. Prophylaxis and scaling and root planing  
procedures may be performed at a future date, after Code D4346, as long as the codes thereafter are  
used appropriately.  
xi.  
Periodontal Maintenance (Code D4910 ) is not appropriate as a follow‐up to Code D4346, since Code  
D4346 isn’t performed to treat periodontal disease.  
xii.  
Consider this procedure code when the patient's periodontium is not healthy, and the periodontal  
disease diagnosis is limited to soft tissue (gingivitis) and is generalized, but has not progressed to the  
advanced disease stage with bone loss (periodontitis).  
3
. Scaling and Root Planing or SRP (Codes D4341, D4342)  
a. Treatment involves the instrumentation of the crown and root surfaces of the teeth to remove plaque,  
calculus, biofilm and stains from these surfaces. The absence of calculus should be evident on post  
treatment radiographs.  
i.  
ii.  
This treatment is considered to be within the scope of a general dentist or a dental hygienist.  
It is common for radiographs to reveal evidence of bone loss of attachment and/or the presence of  
interproximal calculus. It is supported when full mouth periodontal pocket charting demonstrates at  
least 4 mm pocket depths. (MM400) If LIBERTY determines that there are too few teeth with a good  
prognosis in each respective quadrant, we may approve an alternate, more appropriate code.  
(
MM400M)  
iii.  
Scaling and root planing procedures (Codes D4341, D4342) are generally not performed in the same  
quadrants or areas for 2 years following initial completion of these services. In the interim, any  
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localized scaling and root planing would be included within periodontal maintenance procedure (Code  
D4910).  
b. Scaling and root planing is not meant to be reported for an enhanced prophylaxis. If there is no bone loss, a  
more appropriate code might be selected (Codes D1110 or D4346). Rather, it is the judicious removal of  
deposits on the root surface in the presence of periodontal disease. In most cases some form of local  
anesthesia would be indicated to properly render the scaling and root planing procedure. Thus, it would not  
be considered good clinical practice to perform scaling and root planing in the absence of anesthetic.  
c. It would not be considered good clinical practice to perform more than 2 quadrants of SRP at the same visit  
(or, in most cases, on the same date of service) unless a medical or other condition is present that would  
justify such AND there is demonstration of sufficient clinical treatment time to adequately perform judicious  
scaling and root planing of the submitted quadrants. Per clinical review, in the absence of such information,  
LIBERTY may limit the approval to no more than 2 quadrants on any given date of service. (MM401)  
d. Definitive or pre‐surgical scaling and root planing:  
a. For early stages of periodontal disease, this procedure is used as definitive non‐surgical treatment and  
the patient may not need to be referred to a periodontist based upon tissue response and the patient’s  
oral hygiene.  
i. For later stages of periodontal disease, the procedure may be considered pre‐surgical treatment and  
the patient may need to be referred to a periodontist, again based on tissue response and the  
patient’s oral hygiene.  
ii. LIBERTY requires that both definitive and pre‐surgical scaling and root planing be provided at a  
primary care facility before considering referral requests to a periodontal specialist.  
iii. Local anesthetic is commonly used. If it is not used, the reason(s) should be documented. The use of  
topical anesthetics is considered to be a part of and included in this procedure.  
iv. Home care oral hygiene techniques should be introduced and demonstrated.  
v. A re‐evaluation following scaling and root planing should be performed. This re‐evaluation should be  
performed at least 4‐6 weeks later and include: a description of tissue response; pocket depth  
changes; sites with bleeding or exudate; evaluation of the patient’s homecare effectiveness.  
e. It is usually not appropriate to perform Codes D1110 and D4341 on the same date of service. LIBERTY’s  
licensed dental consultants may review documented rationale for any such situations on a case‐by‐case  
basis.  
4
. Periodontal maintenance (Code D4910) at regular intervals should be instituted following scaling and root  
planing if the periodontal condition has improved to a controllable level. Periodontal pocket depths and gingival  
status should be recorded periodically. The patient’s homecare compliance and instructions should be  
documented.  
a. Periodontal maintenance and supportive therapy intervals should begin not less than four weeks following  
primary care treatment of periodontal disease, and should be individualized, although three‐month recalls  
are common for many patients. (MM491)  
b. Periodontal Maintenance (Code D4910) may be allowed for 3 years (or even longer) when there is a history  
of periodontal therapy evident in the patient’s treatment record (by report, by LIBERTY record, or by  
narrative). (MM490)  
5
6
. Periodontal Irrigation (Code D4921)  
a. Periodontal irrigation in the presence of significant gingival inflammation is an elective procedure needed  
when there is significant gingival inflammation (MM4921). If an enrollee chooses to not have irrigation with  
other procedures (i.e., Codes D1110, D4355, D4341, D4342 or D4910), contracted dentists may not limit the  
enrollee’s access to other benefited procedures.  
b. A patient’s refusal of irrigation does not constitute grounds for requesting a patient transfer.  
. Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per  
tooth (Code D4381)  
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a. Locally‐delivered antimicrobials are defined by ADA as adjunctive to periodontal therapy and were intended  
for use in refractory or non‐responsive periodontal pockets. It would not be considered good clinical  
practice within the standard application of Code D4381 to provide this service until after a clinical area was  
determined to be refractory or non‐responsive to standard surgical or non‐surgical pocket reduction  
techniques.  
b. Benefits are not available for localized delivery of antimicrobial when performed with Codes D4341 or  
D4342 in the same quadrant on the same date of service. (MM438)  
c. Dentists may consider the appropriate use of local delivery antimicrobials for chronic periodontitis patients  
as an adjunct to periodontal scaling and root planing (Codes D4341 or D4342) AFTER the following steps:  
i. A clinician has completed periodontal scaling and root planing and allowed a minimum 4‐week healing  
period. Then, the patient’s pockets are re‐probed and re‐evaluated to determine the clinical response to  
the scaling and root planing. (MM439)  
ii. Re‐evaluation confirms that several teeth have localized residual pocket depths of 5 mm’s or greater,  
plus inflammation.  
iii. LIBERTY dental consultants may approve a benefit for localized delivery of antimicrobial agents for non‐  
responsive cases following scaling and root planing on a ‘by report’ basis:  
•
In such cases, benefits may be approved for two teeth per quadrant in any twelve‐month period.  
MM439)  
(
•
Other procedures, such as systemic antibiotics or surgery, should be considered when multiple teeth  
with 5 mm pockets or deeper exist in the same quadrant.  
iv. Treatment alternatives such as systemic antibiotics or periodontal surgery instead of localized delivery of  
antimicrobial agents may be considered when:  
•
•
Multiple teeth with pocket depths of 5 mm’s or greater exist in the same quadrant  
Localized delivery of antimicrobial agents was completed at least 4‐weeks after scaling and root  
planing but a re‐evaluation of the patient’s clinical response confirms that localized delivery of  
antimicrobial agents failed to control periodontitis (i.e., a reduction of localized pocket depths)  
Anatomical defects are present (i.e., intrabony defects)  
•
7
.
Periodontal Surgical Procedures  
a. Periodontal surgical procedures are covered when the following factors are present:  
i. The patient should exhibit a willingness to accept periodontal treatment and practice an appropriate  
oral hygiene regimen prior to consideration for periodontal surgical procedures. (Documentation  
should include history, narrative and/or progress notes).  
ii. Case history, including patient motivation to comply with treatment and oral hygiene status, should be  
documented. (Documentation should include history, narrative and/or progress notes).  
iii. In most cases, there should be evidence of scrupulous oral hygiene for at least three months prior to  
the pre‐authorization for periodontal surgery.  
iv. Consideration for a direct referral to a periodontist would be considered on a ‘by report’ basis for  
complex treatment planning purposes. However, the performance of scaling and root planing, oral  
hygiene instructions and other pre‐ and non‐surgical procedures should be performed by the general  
dentist (before or after the periodontal consultation).  
v. Periodontal surgical procedures are covered only in cases that exhibit a favorable long‐term prognosis.  
Surgical procedures for the retention of teeth that are being used as prosthetic abutments is covered  
only when the teeth would exhibit adequate bone support for the forces to which they are, or will be,  
subjected.  
vi. Gingivectomy/gingivoplasty (Codes D4210 ‐ D4212) periodontal pocket reduction surgical procedures  
may be covered in cases where the pocket depths are 5 mm’s or greater, following soft tissue  
responses to scaling and root planing documented at a periodontal maintenance procedure.  
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Consideration should be given for long‐standing pockets of 5 mm following previous surgical  
intervention, which may or may not require further surgical intervention. (MM402 and MM4210)  
vii. Gingival flap (Codes D4240 and D4241) procedures may be covered in cases where the pocket depths  
are 5 mm’s or greater, following soft tissue responses to scaling and root planing documented at a  
periodontal maintenance procedure, and it is necessary to allow debridement of the root surfaces and  
removal of granulation tissue. (MM424)  
viii. Periodontal osseous pocket reduction surgical procedures (Codes D4260 and D4261) may be covered in  
cases where the pocket depths are 5 mm’s or greater following soft tissue responses to scaling and root  
planing documented at a periodontal maintenance procedure, and there is objective evidence of  
periodontal bone deformity. Consideration should be given for long‐standing pockets of 5 mm  
following previous surgical intervention, which may or may not require further surgical intervention.  
(
MM4260)  
If LIBERTY determines that there are too few teeth with a good prognosis in each respective quadrant,  
we may approve an alternate, more appropriate code. (MM426M)  
b. Periodontal osseous surgery pocket reduction procedures:  
i. May not be covered if:  
a) Pocket depths are 4 mm’s or less and appear to be maintainable by non‐surgical means (i.e.,  
periodontal maintenance and root planing)  
b) Patients are smokers or diabetics whose disease is not being adequately managed  
ii. Periodontal pocket reduction surgical procedures should result in the removal of residual calculus and  
granulation tissue with improved physiologic form of the gingival tissues.  
iii. Osseous surgery and regenerative procedures should also correct and reshape deformities in the  
alveolar bone where indicated.  
c. Clinical crown lengthening (hard tissue) (Code D4249)  
i. This procedure is employed to allow a restorative procedure or crown with little or no tooth structure  
exposed to the oral cavity. (MM440)  
Crown lengthening requires reflection of a flap and is performed in a healthy periodontal environment,  
as opposed to osseous surgery, which is performed in the presence of periodontal disease. Where  
there are adjacent teeth, the flap design may involve a larger surgical area.  
ii. It would not be considered good clinical practice to perform a periodontal surgical procedure on the  
same tooth on the same date of service as a final impression for a fixed or removable prosthesis, as  
healing has not occurred, which could change the tooth / tissue / bone architecture substantially  
affecting the outcome of the prosthesis. (MM441)  
iii. LIBERTY considers the management or alteration of soft tissues performed during a restorative  
procedure or crown preparation with final impressions to be a part of and included in the fee for the  
related procedure. Providers may not charge LIBERTY or the patient a separate fee for Code D4249 if it  
is performed on the same tooth on the same day as preparation and final impressions for a crown.  
d. Bone replacement grafting (Codes D4263 and D4264) in conjunction with osseous surgery involves the use  
of grafts to stimulate periodontal osseous regeneration when the disease process has led to a  
documented deformity of the bone surrounding a tooth or teeth. (MM426)  
e. Biologic materials and/or guided tissue regeneration (Codes D4265 – D4267) may be used during osseous  
surgery to help correct a documented deformity of the bone surrounding a tooth or teeth and is necessary  
to aid in osseous regeneration. (MM425)  
f. Soft or connective tissue grafting (Codes D4277 and D4278) may be used to correct a documented  
mucogingival defect when:  
i. Marginal tissue is insufficient and the tooth or teeth have a good prognosis (MM428)  
(
(
i.e., periodontal prognosis (MM428P), endodontic prognosis (MM428E) and restorative prognosis  
MM428R)).  
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ii. Mucogingival grafting is required in presence of gingival recession or lack of keratinized gingiva and  
generally requires intra‐oral photographic evidence of the mucogingival defect. (MM427)  
Affected teeth must have good endodontic prognosis (MM427E), periodontal prognosis (MM427P) and  
restorative prognosis (MM427R).  
Note: LIBERTY may determine that the graft requested is better described under a different procedure code. (MM427M)  
(
MM428M).  
8
. Provisional splinting (Codes D4320 and D4321) may be necessary when documentation demonstrates the need  
for interim stabilization of mobile teeth. (MM432)  
REMOVABLE PROSTHETICS  
Note: Providers may document the date of service for these procedures to be the date when prosthetic appliances are  
completed.  
A. Complete Dentures (Codes D5110 and D5120)  
1
2
3
4
. Complete dentures are the appliances of last resort, particularly in the mandibular arch. Patients should be fully  
informed of their significant limitations. A complete denture may not be covered if some teeth are still present  
in the arch and extraction of the remaining teeth is not necessary. (MM500)  
. Establishing vertical dimension is considered to be a part of and included in the fee/process for fabricating a  
complete denture (standard, interim or immediate). Therefore, benefits for a complete denture are not limited  
or excluded in any way simply because of the necessity to establish vertical dimension.  
. An immediate complete or removable partial denture includes routine post‐delivery care, adjustments and soft  
liners for six months. A conventional complete or removable partial denture includes routine post‐delivery care  
and adjustments and soft liners for three months.  
. Proper patient education and orientation to the use of removable complete dentures should be part of the  
diagnosis and treatment plan. Educational materials regarding these prostheses are highly encouraged to avoid  
misunderstandings and grievances, and to manage patient expectation.  
B. Immediate Complete Dentures (Code D5130 and D5140)  
1
. These covered dentures are inserted immediately after a patient’s remaining teeth are removed. While  
immediate dentures offer the benefit of never having to be without teeth, they must be relined (refitted on the  
inside) during the healing period after the extractions have been performed.  
2
3
. An immediate complete denture includes routine post‐delivery care, adjustments and soft liners for six months.  
. An immediate complete denture is not a benefit as a temporary denture. Subsequent complete dentures are not  
a benefit within a five‐year period of an immediate denture.  
4
. If prior services are found to be clinically defective due to inadequate technical quality, the providers are  
expected to replace or correct services rendered by them at no additional charge to the member.  
C. Partial Dentures (Codes D5211 – D5281)  
1
. A removable partial denture is normally not indicated for a single tooth replacement of non‐functional second or  
third molars (i.e., no opposing occlusion).  
2
. Removable partial dentures are covered when posterior teeth require replacement on both sides of the same  
arch or multiple edentulous areas are present (excluding non‐functional second or third molars). (MM520)  
Remaining teeth must have a good endodontic prognosis (MM250E) (MM521E) and a good periodontal  
prognosis (MM520P) (MM521P).  
3
4
. An interim partial denture may be needed when the remaining teeth have a good prognosis and the patient has  
an existing partial denture that is not serviceable (MM502) or an initial partial denture is being performed and  
the patient has several missing teeth on both sides of the same arch. (MM504)  
. For a treatment plan that includes both a fixed bridge and a removable partial denture in the same arch, the  
removable partial denture is considered the covered service.  
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5
6
. A unilateral removable partial denture is rarely appropriate. Best practices include replacing unilateral missing  
teeth with a fixed bridge or implant. (MM520)  
. Endodontic, periodontal and restorative treatment should be completed prior to fabrication of a removable  
partial denture.  
7
8
9
. Abutment teeth should be restored prior to the fabrication of a removable partial denture and would be  
covered if the teeth meet the same standalone benefit requirements of a single crown.  
. Removable partial dentures should be designed so that they do not harm the remaining teeth and/or  
periodontal tissues, and to facilitate oral hygiene.  
. Materials used for removable partial dentures must be strong enough to resist breakage during normal function,  
nonporous, color stable, esthetically pleasing, non‐toxic and non‐abrading to the opposing or supporting  
dentition.  
1
0. Partial dentures with acrylic clasps (such as Valplast or others, also known as “Combo Partials”) are considered  
under the coverage for Codes D5213 and D5214.  
D. Proper patient education and orientation to the use of immediate complete or partial dentures should be part of the  
diagnosis and treatment plan. Educational materials regarding these prostheses are highly encouraged to avoid  
misunderstandings and grievances, and to manage patient expectation.  
E. Replacement of an existing complete or partial denture:  
1
. Removable complete or partial dentures are not covered for replacement if an existing appliance can be made  
satisfactory by reline or repair. (MM501 and MM521)  
2
. Complete or partial dentures are not a covered if a clinical evaluation reveals the presence of a satisfactory  
appliance, even if a patient demands replacement due to their own perceived functional and/or cosmetic  
concerns.  
F. Complete or partial denture adjustments (Codes D5410 – 5422):  
1
2
3
. An immediate complete or removable partial denture includes routine post‐delivery care, adjustments and soft  
liners for six months.  
. A conventional complete or removable partial denture includes routine post‐delivery care and adjustments for  
three months.  
. A prospective or retrospective request for a complete or partial denture adjustment must include  
documentation that the appliance is ill‐fitting. (MM541)  
G. Repairs to complete and partial removable dentures (Codes D5511 – D5671) must include documentation that  
demonstrates the appliance is broken or in need of repair. (MM560)  
H. Relines for complete and partial removable dentures (Codes D5730 – D5761):  
1
. Supporting soft tissues and bone shrink over time, resulting in decreased retention and/or stability of the  
appliance.  
2
. A rebase or reline of a partial or complete denture would be covered (subject to plan limitations) if  
documentation demonstrates that the appliance is ill‐fitting and may be corrected by rebasing or relining,  
resulting in a serviceable appliance. (MM570)  
I. Interim removable partial dentures (Codes D5820 and D5821)  
1
. These appliances are only intended to temporarily replace extracted teeth during the healing period, prior to  
fabrication of a subsequent, covered, fixed or removable partial denture. Benefits may not exist for both an  
interim and definitive partial denture.  
2
3
. The submitted documentation must show that the existing partial denture is unserviceable. (MM582)  
. Removable partial dentures are covered when posterior teeth require replacement on both sides of the same  
arch or multiple edentulous areas are present (excluding non‐functional second or third molars) and the  
remaining teeth have a good prognosis. (MM583) (MM483M)  
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J. Tissue conditioning (Codes D5850 and D5851) may be required when documentation shows that the tissue under a  
removable appliance is unhealthy or must be treated prior to fabricating a new appliance or rebasing or relining an  
existing appliance. (MM585)  
K. A precision attachment (Code D5862) or the replacement of a part of a precision or semi‐precision attachment  
requires documentation that it is medically necessary to stabilize a removable appliance. (MM586)  
ORAL SURGERY  
A. Extractions (Codes D7111 – D7251)  
1
. Each dental extraction should be based on a clearly recorded diagnosis for which extraction is the treatment of  
choice of the dentist and the patient.  
2
. For extraction of a deciduous tooth (Codes D7111 and D7140) there must be evidence of medical necessity  
showing that the tooth has pathology and will not exfoliate soon (within the next six months) (MM710) or a  
patient complaint of acute pain.  
3
. Extractions may be indicated in the presence of non‐restorable caries, untreatable periodontal disease, pulpal  
and periapical disease not amendable to endodontic therapy, to facilitate surgical removal of a cyst or  
neoplasm, or when overriding medical conditions exist, providing compelling justification to eliminate existing or  
potential sources of oral infection. (MM721)  
a. Extractions of erupted teeth  
i. An uncomplicated extraction (Code D7140) of an erupted or exposed root includes removal of all tooth  
structure, minor smoothing of socket bone and closure, as necessary. Extraction of an erupted tooth may  
be needed when the tooth has significant decay, is causing irreversible pain and/or infection, or is  
impeding the eruption of another tooth. (MM700)  
ii. A surgical extraction of an erupted tooth (Code D7210) requires removal of bone and/or sectioning the  
tooth, including elevation of a mucoperiosteal flap if indicated.  
b. An impacted tooth is “An unerupted or partially erupted tooth that is positioned against another tooth,  
bone, or soft tissue so that complete eruption is unlikely.” (CDT)  
i. Extraction of a soft tissue impaction (Code D7220) is a tooth with the occlusal surface covered by soft  
tissue, and extraction requires elevation of a mucoperiosteal flap.  
ii. Extraction of a partial bony impaction (Code D7230) is a tooth with part of the crown covered by bone  
and requires elevation of a mucoperiosteal flap and bone removal.  
iii. Extraction of a completely bony impaction (Code D7240) is a tooth with most or all of the crown covered  
with bone and requires elevation of a mucoperiosteal flap and bone removal.  
iv. Extraction of a complicated completely bony extraction (Code D7241) requires documentation of unusual  
surgical complications.  
c. Removal of residual tooth roots (Code D7250) requires cutting of soft tissue and bone and includes closure.  
d. Coronectomy (Code D7251) is an intentional partial removal of an impacted tooth when a neurovascular  
complication is likely if the entire impacted tooth is removed.  
e. The prophylactic removal of an impacted or unerupted tooth or teeth that appear(s) to exhibit an  
unimpeded path of eruption and/or exhibit no active pathology is not covered. (MM722) During our clinical  
review of requests for extraction of impacted and/or erupted teeth, LIBERTY may determine that treatment  
better fits the description of a different, more appropriate procedure code. In that situation, LIBERTY may  
approve the extraction under a different code. (MM722M)  
i.  
The removal of asymptomatic, unerupted, third molars in the absence of active pathology may not be  
covered.  
ii.  
Pericoronitis is considered to be pathology. By definition, completely covered and unerupted third  
molars cannot exhibit pericoronitis.  
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iii.  
Narratives describing the presence of pericoronitis on a fully erupted tooth are ambiguous. In such  
cases, the radiographic or photographic presentation will be the determining factor in the  
determination of coverage.  
B. Other Surgical Procedures  
1
2
3
4
5
.
.
.
.
.
Removal of residual tooth roots (Code D7250) may be needed when the residual tooth root is pathological  
or is interfering with another procedure. (MM725)  
Sinus perforation or oroantral fistula closure (Code D7260) requires documentation that there is a  
pathological opening into the sinus. (MM726)  
Tooth re‐implantation and/or stabilization of an accidentally evulsed or displaced tooth (Code D7270)  
requires documentation that a tooth or teeth have been accidentally evulsed or displaced. (MM727)  
A biopsy of oral tissue (Codes D7285 and D7286) requires documentation that there is a suspicious lesion in  
the mouth that needs evaluation and the harvesting of oral tissue. (MM728)  
A surgical procedure to facilitate tooth movement (Codes D7292 – D7295) requires documentation that  
demonstrates the medical necessity of a surgical procedure to facilitate appropriate tooth positioning.  
(
MM729)  
C. Alveoloplasty‐Preparation of Ridge (Codes D7310 – D7321) requires documentation that demonstrates the medical  
necessity for the surgical recontouring of the alveolus. (MM731)  
D. Excision of soft tissue or intra‐osseous lesions (Codes D7410 – D7461) requires documentation of the presence of an  
intra‐oral lesion and the medical necessity to remove it. (MM741)  
E. Excision of bone tissue (Codes D7472 and D7473) (an exostosis) requires documentation that a bony growth  
interferes with the ability to function or wear a prosthesis. (MM747)  
F. Incision and drainage of an abscess (Codes D7510 ‐ D7521) requires documentation that shows an oral infection that  
requires drainage. (MM751)  
G. Removal of a foreign body (Code D7530), non‐vital bone or a tooth fragment requires documentation that it is  
medically necessary to remove it. (MM753)  
H. Open/closed reduction of a fracture (Codes D7610 – D7640) requires documentation that demonstrates evidence of  
a broken jaw. (MM760)  
I. Reduction of dislocation (Codes D7810 and D7820) and management of other temporomandibular joint  
dysfunctions require documentation showing a dislocation or other pathological condition of the  
temporomandibular joint. (MM781)  
J. Repair of traumatic wounds (Code D7910) and other repair procedures requires documentation showing that it is  
medically necessary to suture a traumatic wound and/or other repair procedures. (MM791)  
K. A frenulectomy (Code D7960) requires documentation that demonstrates evidence that a muscle attachment is  
interfering with proper oral development or treatment. (MM796)  
L. Excision of hyperplastic tissue (Code D7970) or reduction of a fibrous tuberosity (Code D7972) requires  
documentation that demonstrates the medical necessity of removing redundant soft tissue to facilitate a removable  
prosthesis. (MM797)  
M. Excision of pericoronal gingiva (Code D7971) requires documentation that demonstrates the medical necessity of  
removing inflammatory or hypertrophied tissues surrounding partially erupted or impacted teeth. (MM7971)  
ADJUNCTIVE SERVICES  
A. Unclassified Treatment  
1
. Palliative Treatment (Code D9110)  
a. Typically reported on a “per visit” basis for emergency treatment of dental pain.  
b. The submitted documentation must show the presenting issue and/or the emergency treatment provided  
that was medically necessary for the procedure. (MM911)  
2
. Fixed Partial Denture Sectioning (Code D9120)  
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a. This procedure involves separation of one or more connections between abutments and/or pontics when  
some portion of a fixed prosthesis is to remain intact and serviceable following sectioning and extraction or  
other treatment and includes all recontouring and polishing of retained portions.  
b. The submitted documentation must show that it is medically necessary to section and remove part of a fixed  
partial denture and that the remaining tooth or teeth have a good prognosis. (MM912)  
B. Anesthesia  
1
. Local or regional block anesthesia in or not in conjunction with operative or surgical procedures (Code D9210):  
a. Local or regional block anesthesia is considered to be part of and included in conjunction with operative or  
surgical procedures.  
b. Submitted documentation must show that it is necessary to anesthetize part of the mouth when it is not in  
conjunction with operative or surgical procedures. (MM921)  
2
. Deep Sedation/General Anesthesia or Intravenous moderate sedation/analgesia (Codes D9223 and D9243)  
a. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate  
anesthesia and non‐invasive monitoring protocol and remains in continuous attendance of the patient.  
Anesthesia services are considered completed when the patient may be safely left under observation of  
trained personnel and the doctor may leave the room to attend to other patients or duties.  
b. The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetics effect  
upon the central nervous system and not dependent on the route of administration. It is expected that  
dentists performing anesthesia on patients be properly licensed by their state’s regulatory body and comply  
with all monitoring requirements dictated by the licensing body.  
c. LIBERTY provides benefits for covered General Anesthesia (“GA”) or Intravenous (“IV”) Sedation in a Dental  
Office Setting ONLY when medical necessity is demonstrated by the following requirements, conditions and  
guidelines (MM920):  
i. A medical condition that requires monitoring (e.g., cardiac, severe hypertension);  
ii. An underlying medical condition exists which would render the patient non‐compliant without the GA or  
IV Sedation (e.g., cerebral palsy, epilepsy, developmental/intellectual disability, Down’s syndrome);  
iii. Documentation of failed conscious sedation (if available);  
iv. A condition where severe infection would render local anesthesia ineffective.  
. Requirements for Documentation:  
3
a. The medical necessity for treatment with GA or IV Sedation in a dental office setting must be clearly  
documented in the patient’s dental record and submitted by the treating dentist;  
b. Pre‐authorization and submission requirements:  
i.  
Prior to providing GA or IV Sedation in a dental office setting, all necessary medical and dental  
documentation, including the dental treatment plan, must be reviewed and approved by LIBERTY.  
Submit the patient’s dental record, health history, charting of the teeth and existing oral conditions,  
diagnostic radiographs (except where not available due to conditions listed above) and intra‐oral  
photographs.  
ii.  
iii.  
iv.  
Submit a written narrative documenting the medical necessity for general anesthesia or IV Sedation;  
Treatment rendered as an emergency, when pre‐authorization was not possible, requires submission of  
a complete dental treatment plan and a written narrative documenting the medical necessity for the GA  
or IV Sedation.  
c. The dental office has established, implemented and provided LIBERTY with approved sedation and general  
anesthesia policies and procedures that comply with the American Dental Association Guidelines for the Use  
of Sedation and General Anesthesia by Dentists.  
4
. The following oral surgical procedures may qualify for GA or IV Sedation:  
a. Removal of impacted teeth;  
b. Surgical root recovery from maxillary antrum (sinus);  
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CLINICAL DENTISTRY GUIDELINES
c. Surgical exposure of impacted or unerupted cuspids (for orthodontic cases, the orthodontic treatment must  
have been approved in advance);  
d. Radical excision of lesions in excess of 1.25 cm.  
e. Children under the age determined by applicable state regulations with an extensive treatment plan may  
qualify for a GA or IV Sedation benefit.  
5
6
. Use of Nitrous Oxide (Code D9230) requires documentation of medical necessity to alleviate discomfort or  
anxiety associated with dental treatment (once per visit). (MM923)  
. Non‐intravenous Conscious Sedation (Code D9248) (Includes non‐IV minimal and moderate sedation)  
a. This is a medically controlled state of depressed consciousness while maintaining the patient’s airway,  
protective reflexes and the ability to respond to stimulation or verbal commands. It includes non‐  
intravenous administration of sedative and/or analgesic agent(s) and appropriate monitoring.  
i. The submitted documentation must demonstrate the medical necessity of non‐IV conscious sedation.  
(
MM924)  
ii. The level of anesthesia is determined by the anesthesia provider’s documentation of the anesthetics  
effect upon the central nervous system and not dependent on the route of administration.  
C. Professional Consultation (Code D9310)  
1
. This is a patient encounter with a practitioner whose opinion or advice regarding evaluation and/or  
management of a specific problem; it may be requested by another practitioner or appropriate source and it  
includes an oral evaluation.  
2
3
. The consulted practitioner may initiate diagnostic and/or therapeutic services.  
. The submitted documentation must demonstrate the medical necessity of assistance in determining the  
treatment required for a specific condition. (MM931)  
D. Professional Visits (Codes D9410 and D9420)  
1
. Hospital, house, extended care or ambulatory surgical center call  
a. Includes nursing homes, long term care facilities, hospice sites, institutions, hospitals or ambulatory surgical  
centers.  
b. Services delivered to the patient on the date of service are documented separately using the applicable  
procedure codes.  
c. The submitted documentation must demonstrate the medical necessity of treatment outside of the dental  
office. (MM942)  
2
. Office visit for observation or case presentation during or after regularly scheduled hours (Code D9440)  
a. This is for an established patient and is not performed on the same day as evaluation.  
b. The submitted documentation must demonstrate the medical necessity of an office visit or case  
presentation during or after regularly scheduled office hours. (MM943)  
E. Drugs (Codes D9610 – D9630)  
1
. Administration of one or more parenteral drugs or dispensing of drugs or medicaments for home use require  
submitted documentation demonstrating the medical necessity of the drugs or medicaments for treating a  
specific condition. (MM963)  
F. Miscellaneous Services  
1
. Treatment of post‐surgical complications or unusual circumstances (by report) (Code D9930) must provide  
documentation demonstrating the medical necessity of the procedure.  
2
. Occlusal Guard (Code D9940)  
a. This is a removable dental appliance designed to minimize the effects of bruxism and other occlusal factors.  
b. This must be supported by documentation demonstrating the medical necessity fabricating, adjusting or  
repairing/relining an occlusal guard to minimize the effects of bruxism or TMJ symptoms/pathology.  
(
MM994)  
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RETROSPECTIVE REVIEW  
Prospective and retrospective review will require documentation that demonstrates medical necessity. This  
documentation can include diagnostic radiographic or photographic images (MM0350), the results of tests or  
examinations, descriptions of conditions in progress notes and/or a written narrative providing additional information.  
In cases where objective information (such as diagnostic images) conflicts with subjective information (such as written  
descriptions), objective information will be given preference in making a determination.  
Retrospective review of services that had been previously pre‐authorized will require documentation confirming that  
the procedure(s) was (were) completed as authorized and within the standard of care as defined by Liberty Dental Plan’s  
Criteria Guidelines and Practice Parameters. (MMPROG)  
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