Covered Dental Codes

2024 | Preventive, Basic, and Major Services Covered Dental Codes 0

Your guide to no-surprises dental care Every Devoted Health plan includes dental benefits to make taking care of your teeth easy and affordable. The best way to avoid surprise costs at the dentist is to ask for an estimate before you get any care. This guide can help. It lists all the covered dental codes for 2024 Devoted Health plans that cover: • Preventive services like cleanings and X-rays • Basic services like fillings and extractions • Major services like dentures, crowns, and root canals This guide is for plans that cover the services listed above through Liberty Dental or Delta Dental. Check the back of your member ID card to see if your coverage is through Liberty or Delta. You may need prior authorization for some services. There are just a few cases where your coverage might be different: • If your plan only covers preventive and basic services, there's a different list of covered codes. Visit devoted.com/dental/codes-2024 or text or call us to get a copy. • If your plan has a dental benefit card or yearly allowance that's not through Liberty or Delta, there’s no list of covered codes. See your plan documents for more details about how your dental benefit works. • If you also have Medicaid benefits, Medicaid may cover extra dental services in addition to what your Devoted Health plan covers. Call us for details. For more details about your plan’s dental coverage, visit devoted.com/find-plan-documents to look up your plan documents. Questions? Text 866-85 or call us at 1-800-338-6833 (TTY 711). We’re here Monday to Friday, 8am to 8pm (from October 1 to March 31, 8am to 8pm, 7 days a week). Y0142_24S264_M 1

CODE SERVICE FREQUENCY BENEFIT DETAILS Preventive Exams D0120 Routine check-up exam 2 procedures per Not covered within 6 months of calendar year receiving D0150 or D0180 D0140 Dental evaluation to 2 procedures per Not covered with any other exam evaluate a specific calendar year code on same day problem or complaint D0150 Comprehensive new 1 procedure every 3 Not covered within 3 years of patient exam calendar years receiving D0180 D0180 Exam for a new or 1 procedure every 3 Not covered within 3 years of established patient with calendar years receiving D0150 gum disease or risk factors such as smoking or diabetes D0191 Assessment of a Patient 2 procedures per Only covered on same day as calendar year receiving D9995 or D9996. Not covered when another exam code is submitted on same day. X-rays D0210 Full mouth set of X-rays 1 procedure every 3 Not covered within 3 years of calendar years receiving D0330 D0220 X-ray of entire tooth (first 1 procedure per Not covered on same day as image) date of service D0210 or D0330 D0230 X-ray of entire tooth Unlimited Not covered on same day as (additional images) D0210 or D0330 D0270 X-ray (bitewing 1 bitewing Not covered in same year as D0272 procedures) for diagnosing procedure code per D0210 D0273 cavities between teeth in calendar year the back of the mouth D0274 D0277 D0330 Panoramic X-ray of all the 1 procedure every 3 Not covered within 3 years of teeth and surrounding years receiving D0210 bone 2

CODE SERVICE FREQUENCY BENEFIT DETAILS D0350 2D photographic image 1 procedure per Only covered when performed on calendar year same day as D9995 or D9996 D0801 3D dental surface scan, 1 of (D0801, D0802) direct every calendar year D0802 3D dental surface scan, 1 of (D0801, D0802) indirect every calendar year D0803 3D facial surface scan, 1 of (D0803, D0804) direct every calendar year D0804 3D facial surface scan, 1 of (D0803, D0804) indirect every calendar year Cleanings D1110 Routine adult dental 2 procedures per Cannot be performed on the cleaning calendar year same day as another type of cleaning (D4355, D4910, D4341, D4342) or gum surgery (D4210, D4211, D4240, D4241, D4260, D4261) Fluoride D1208 Topical fluoride treatment 2 procedures per 2 topical fluoride treatments calendar year (D1208) or desensitizing medication applications (D9910) per calendar year Comprehensive Fillings D2140 Silver-colored filling on Unlimited 1 procedure per surface per D2150 front, middle or back teeth tooth every 2 years D2160 D2161 D2330 White-colored filling on Unlimited 1 procedure per surface per D2331 front teeth tooth every 2 years D2332 D2335 3

CODE SERVICE FREQUENCY BENEFIT DETAILS D2390 White-colored filling that Unlimited 1 procedure per tooth every 5 replaces entire outer years surface of a front tooth D2391 White-colored filling on Unlimited 1 procedure per surface per D2392 middle or back teeth tooth every 2 years D2393 D2394 Crowns D2740 Cap (crown) made of Unlimited 1 crown code or bridge retainer D2750 metal, porcelain, porcelain code (see covered bridge codes D2752 fused to metal or titanium below) per tooth every 5 years D2753 D2790 D2792 D2794 Other Crown Services D2910 Recement (reglue) an old Unlimited 1 procedure per tooth every 2 inlay, onlay, veneer or calendar years partial crown that has fallen off D2920 Recement (reglue) an old Unlimited 1 procedure per tooth every 2 crown that has fallen off calendar years, only covered 6 months after initial placement of crown D2940 Protective filling to relieve Unlimited 1 procedure per tooth per pain or promote healing, lifetime which is usually meant to be a temporary solution D2950 Buildup filling that is Unlimited 1 buildup procedure code placed to prepare a tooth (D2950, D2952, D2954) per for a new cap (crown) tooth every 5 years, not covered when a separate filling code is billed on the same tooth on the same day 4

CODE SERVICE FREQUENCY BENEFIT DETAILS D2951 Pin used to retain a large Unlimited 1 procedure per tooth every 5 filling years, not covered when billed with D2950, D2952 or D2954 on the same day D2952 Custom-made post and Unlimited 1 buildup procedure code buildup filling that is (D2950, D2952, D2954) per usually fabricated by a tooth every 5 years, not covered dental lab, placed after a when a separate filling code is root canal to prepare the billed on the same tooth on the tooth for a cap (crown) same day D2953 Each additional custom- Unlimited 1 procedure per tooth every 5 made post years, only covered when the tooth receives D2952 on same day D2954 Pre-made post and buildup Unlimited 1 buildup procedure code filling that is not fabricated (D2950, D2952, D2954) per by a dental lab, placed tooth every 5 years, not covered after a root canal to when a separate filling code is prepare tooth for a cap billed on the same tooth on the (crown) same day D2980 Repair of a single crown Unlimited 1 procedure per tooth every 5 (i.e. chipped porcelain) years, covered only after 2 years with filling material from date of crown placement Root Canals D3310 Initial root canal on a front, Unlimited 1 initial root canal procedure D3320 middle or back tooth code (D3310, D3320, D3330) and D3330 1 retreat root canal procedure code (D3346, D3347, D3348) per tooth per lifetime D3346 Root canal retreatment Unlimited 1 initial root canal procedure D3347 (redo) on a front, middle or code (D3310, D3320, D3330) and D3348 back tooth 1 retreat root canal procedure code (D3346, D3347, D3348) per tooth per lifetime 5

CODE SERVICE FREQUENCY BENEFIT DETAILS Gum Surgery D4210 Surgical procedures that 1 procedure code Not covered if another cleaning D4211 treat periodontal disease per quadrant every (D1110, D4355, D4910) or deep D4240 (gum disease) to promote 3 calendar years, cleaning (D4341, D4342) is healing of gums and not to exceed 4 performed on the same day D4241 underlying bone unique quadrants D4260 every 3 calendar D4261 years Other Gum-Related Services D4341 Deep cleaning that’s 1 deep cleaning Not covered if another cleaning D4342 performed to remove procedure code per (D1110, D4355, D4910) or gum bacteria, plaque and tartar quadrant every 3 surgery procedure (D4210, below the gumline along calendar years, not D4211, D4240, D4241, D4260, the tooth roots to exceed 4 unique D4261) is performed on same quadrants every 3 day calendar years D4355 Cleaning that’s performed 1 procedure every 3 Not covered if another cleaning when there’s too much calendar years (D1110, D4910), deep cleaning tartar on the teeth to do an (D4341, D4342), or gum surgery effective exam procedure (D4210, D4211, D4240, D4241, D4260, D4261) is performed on same day D4381 Antimicrobial medicine 2 procedures per Only covered on same day that applied within the inflamed tooth per calendar D4910 is performed gum pocket around a tooth year, limited to 2 teeth per quadrant D4910 Routine dental cleaning for 3 procedures per Only covered with previous an adult with a history of calendar year history of receiving a deep gum disease cleaning (D4341, D4342) or gum surgery (D4210, D4211, D4240, D4241, D4260, D4261) Complete Dentures D5110 Complete upper denture 1 procedure every 5 Not covered within 5 years of (for patients missing all calendar years receiving an upper partial their upper teeth) denture (D5211, D5213, D5225) D5120 Complete lower denture 1 procedure every 5 Not covered within 5 years of (for patients missing all calendar years receiving a lower partial denture their bottom teeth) (D5212, D5214, D5226) 6

CODE SERVICE FREQUENCY BENEFIT DETAILS D5130 Complete upper denture 1 procedure per Only covered on or after the day that is delivered on the lifetime of upper tooth extractions same day of extracting remaining upper teeth. This denture is meant to be temporary and is called an immediate complete upper denture. D5140 Complete lower denture 1 procedure per Only covered on or after the day that is delivered on the lifetime of lower tooth extractions same day of extracting remaining lower teeth. This denture is meant to be temporary and is called an immediate complete lower denture. Partial Dentures D5211 Upper partial denture (for 1 procedure code Not covered within 5 years of D5213 patients missing some of every 5 calendar receiving an upper unilateral D5225 their upper teeth) years removable partial denture (D5284, D5286) D5212 Lower partial denture (for 1 procedure code Not covered within 5 years of D5214 patients missing some of every 5 calendar receiving a lower unilateral D5226 their lower teeth) years removable partial denture (D5284, D5286) D5221 Upper partial denture that 1 procedure code Not covered on same day as D5223 is delivered on the same per lifetime receiving an upper partial D5227 day of extracting some denture (D5211, D5213, D5225) upper teeth. This denture is meant to be temporary and is called an immediate upper partial denture. D5222 Lower partial denture that 1 procedure code Not covered on same day as D5224 is delivered on the same per lifetime receiving a lower partial denture D5228 day of extracting some (D5212, D5214, D5226) lower teeth. This denture is meant to be temporary and is called an immediate lower partial denture. 7

CODE SERVICE FREQUENCY BENEFIT DETAILS D5284 Unilateral removable 1 procedure code Not covered within 5 years of D5286 partial denture for the per arch every 5 receiving an upper partial upper or lower arch. This is calendar years denture (D5211, D5213, D5225) or a ‘quadrant’ denture lower partial denture (D5212, meant to only replace 1-2 D5214, D5226) missing teeth. Denture Adjustments D5410 Adjustment of an upper 2 procedures per Not covered within 6 months of D5421 complete or upper partial calendar year receiving an upper complete denture denture (D5110) or upper partial denture (D5211, D5213, D5225) D5411 Adjustment of a lower 2 procedures per Not covered within 6 months of D5422 complete or lower partial calendar year receiving a lower complete denture denture (D5120) or lower partial denture (D5212, D5214, D5226) Denture Repairs D5511 Repair of an upper or lower 1 procedure code Not covered within 6 months of D5512 complete denture base per complete receiving an upper complete denture base every denture (D5110) or lower 5 calendar years complete denture (D5120) D5520 Replace missing or broken 1 procedure per Not covered within 6 months of teeth on a complete complete denture receiving an upper complete denture per calendar year denture (D5110) or lower complete denture (D5120) D5611 Repair of an upper or lower 1 procedure code Not covered within 6 months of D5612 partial denture base or per partial denture receiving an upper partial D5621 framework base or framework denture (D5211, D5213, D5225) or every 5 calendar lower partial denture (D5212, D5622 years D5214, D5226) D5630 Repair or replace a broken 1 procedure per Not covered within 6 months of clasp on partial denture partial denture receiving an upper partial every 5 calendar denture (D5211, D5213, D5225) or years lower partial denture (D5212, D5214, D5226) 8

CODE SERVICE FREQUENCY BENEFIT DETAILS D5640 Replace a broken tooth or 1 procedure code Not covered within 6 months of D5650 add tooth to partial per partial denture receiving an upper partial denture per calendar year denture (D5211, D5213, D5225) or lower partial denture (D5212, D5214, D5226) D5660 Add a clasp to partial 1 procedure per Not covered within 6 months of denture partial denture receiving an upper partial every 5 years denture (D5211, D5213, D5225) or lower partial denture (D5212, D5214, D5226) Denture Rebase D5710 Rebase of an upper 1 procedure code Not covered within 6 months of D5720 complete or upper partial per denture every 5 receiving an upper complete denture calendar years (D5110) or upper partial denture (D5211, D5213, D5225) D5711 Rebase of a lower 1 procedure code Not covered within 6 months of D5721 complete or lower partial per denture every 5 receiving a lower complete denture calendar years (D5120) or lower partial denture (D5212, D5214, D5226) Denture Relines D5730 Chairside or laboratory 1 procedure code Not covered within 6 months of D5740 reline of upper complete every 2 calendar receiving an upper complete D5750 and upper partial dentures years (D5110) or upper partial denture (D5211, D5213, D5225) D5760 D5731 Chairside or laboratory 1 procedure code Not covered within 6 months of D5741 reline of lower complete every 2 calendar receiving a lower complete D5751 and lower partial dentures years (D5120) or lower partial denture (D5212, D5214, D5226) D5761 D5765 Soft reline for complete or 1 procedure per Not covered within 6 months of partial dentures denture per receiving an upper complete calendar year denture (D5110), upper partial denture (D5211, D5213, D5225), lower complete denture (D5120), or lower partial denture (D5212, D5214, D5226) 9

CODE SERVICE FREQUENCY BENEFIT DETAILS Other Denture Services D5850 Tissue conditioner applied 2 procedures per Covered after delivery of to inside of upper denture upper denture every immediate upper denture to help gums heal 5 calendar years (D5130, D5221, D5223, D5227) and before fabrication of new upper denture (D5110, D5211, D5213, D5225), not payable after delivery of new upper denture D5851 Tissue conditioner applied 2 procedures per Covered after delivery of to inside of lower denture lower denture every immediate lower denture to help gums heal 5 calendar years (D5140, D5222, D5224, D5228) and before fabrication of new lower denture (D5120, D5212, D5214, D5226), not payable after delivery of new lower denture Bridge (pontics and retainers) D6210 The fake tooth (pontic) of Unlimited 1 pontic code per edentulous D6212 the bridge that replaces space every 5 calendar years D6214 the missing tooth (edentulous space). D6240 Pontics are made of metal, D6242 porcelain, porcelain fused D6243 to metal or titanium. D6245 D6545 The caps (retainers) of the Unlimited 1 retainer code or crown code D6548 bridge that are placed on (see covered crown codes D6740 natural teeth. Retainers above) per tooth every 5 are made of metal, calendar years, not covered for a D6750 porcelain, porcelain fused bridge supported by implants D6752 to metal or titanium. D6753 D6790 D6792 D6794 10

CODE SERVICE FREQUENCY BENEFIT DETAILS Other Bridge Services D6930 Recement (reglue) a bridge Unlimited 1 procedure per calendar year, that has fallen off not covered within 6 months of receiving bridge retainer (see covered retainer codes above) D6980 Repair of the pontic or Unlimited 1 procedure every 2 calendar retainer portion of bridge years, not covered within 6 months of receiving bridge pontic (see covered pontic codes above), not covered for a bridge supported by implants Extractions and Oral Surgery D7140 Routine or surgical Unlimited 1 extraction procedure code per D7210 extractions of erupted tooth per lifetime D7250 teeth or exposed roots D7310 Reshaping of bone at 1 alveoloplasty Only covered if performed on D7311 extraction site(s) in procedure code per same day as extractions preparation for a denture quadrant per procedure (alveoloplasty) lifetime D7440 Removal of malignant Unlimited Only covered if procedure is D7441 tumor in the upper or performed by a board certified lower jaw oral and maxillofacial surgeon Miscellaneous Services D9110 Minor dental procedure to 1 procedure per Only covered for an in-office relieve pain or discomfort calendar year dental emergency visit D9230 Nitrous Oxide (laughing 1 procedure per Only covered if comprehensive gas) sedation date of dental care (D2140-D9910) is performed service on same day D9910 Desensitizing medication 2 procedures per 2 topical fluoride treatments for tooth calendar year (D1208) or desensitizing medication applications (D9910) per calendar year, does not cover bases, liners or adhesives under fillings 11

CODE SERVICE FREQUENCY BENEFIT DETAILS D9930 Treatment for 1 procedure per Not covered for dry socket complications after a tooth calendar year treatment within 30 days of an extraction (including dry extraction sockets) or other surgical procedure D9944 Top or bottom hard 1 nightguard every 5 Only covered for patients who nightguard that is used to calendar years clench and/or grind their teeth, protect the teeth from does not cover appliances for clenching and/or grinding treating sleep apnea, snoring or complex temporomandibular disorders D9995 Virtual/remote dental 2 procedures per Only covered if a D0140 or D0191 D9996 exams calendar year exam is performed on the same day Devoted Health is an HMO and/or PPO plan with a Medicare contract. Our D-SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal. 12

If you're a Devoted Health member, call: Questions? Call us. 1-800-338-6833 1-800-385-0916 TTY 711 TTY 711 Or text us at 866-85 15