Consultant's Corner

Occasionally, a dentist or staff member may question the benefit determination of a claim and may wish to submit a request for reconsideration/appeal of the claim.

So that we may make a timely review of all reconsideration/appeal requests we ask for the following:

All reconsideration/appeal requests for pre-determinations or claims are requested to be type-written and to include:

• A type-written cover letter signed by the treating dentist describing the specific reason why the reconsideration is being requested (including tooth numbers and procedures). The letter should reference the original claim number, patient name, date of service, and current date.
• Any additional legible clinical record documentation which might support the reconsideration/appeal request. Delta Dental national processing policy only allows dental consultants to consider information contained in the contemporaneous legal clinical record when evaluating reconsideration/appeal requests. Narratives cannot be considered as support for a reconsideration request.

The original benefit determination of the claim or pre-determination will be upheld unless it is found that a specific error was made or additional clinical record documentation supports the request for reconsideration/appeal.

Reconsideration/appeal requests must be submitted within six (6) months of the date of the original explanation of benefits/payment remittance advice.

Dentists should submit their reconsideration/appeal request to:
       Director, Professional Relations
       Northeast Delta Dental
       One Delta Drive
       PO Box 2002
       Concord, NH 03302-2002

Providing more than one hour of intravenous moderate (conscious) sedation, deep sedation, or general anesthesia for routine dental procedures is considered to be unusual and, therefore, Northeast Delta Dental, in accordance with our contracts and Delta Dental Plans Associations’ National Processing Policies, will allow benefits for a maximum of one hour of anesthesia. However, anesthesia time in excess of one hour may be considered upon consultant review when there is documentation of exceptional circumstances in the clinical record. IV sedation and general anesthesia can only be considered for benefits when performed in conjunction with contractually covered oral surgery and surgical implant procedures.

Additional anesthesia time may be requested at the time of claim submission or upon a reconsideration request. However, in order to avoid reconsideration requests, we recommend that additional time be requested at the time of claim submission. If making such a request, please indicate “Request consultant review for anesthesia” in the remarks section of the claim and include complete clinical and anesthesia records with your submission. Placing this comment on your claim will ensure that your request for additional anesthesia time is considered by our consultants.

When required for specific procedures, it is expected that a periodontal charting should be contemporaneous, accurate, and complete. The periodontal charting should provide a complete record of the pocket depths, mobilities, recession, (measurement in mm from CEJ to free gingival margin), mucogingival junction (MGJ-measurement in mm from gingival margin to MGJ), location of implants, etc.

Delta Dental’s national processing policies define MGJ documentation as the measurement in millimeters from the gingival margin to the muco-gingival junction (where the attached gingiva ends and non-attached tissue begins), and is essential for submissions for muco-gingival surgeries.

Delta Dental National Processing Policy’s emphasis is on the importance of clinical notes vs. narratives when submitting explanations or justifications on your pre-determinations or claims. The patient record/clinical notes are considered a legal document and are contemporaneous. The only acceptable legal written documentation for utilization review are the contemporaneous treatment notes.  Legal clinical notes (operative notes) include radiographic and photographic images, periodontal chartings, anesthesia records, referral notes, pathology reports (whichever may be applicable) is very important. A narrative may be included; however, it should be supported by the information documented in the legal clinical notes.

Please note that radiographic images must be less than 2 years old, of diagnostic quality; properly oriented if submitted for documentation purposes, and with the date of exposure and a patient identifier indicated on all images. Photographic images, if available, should be labeled with date, patient identifier, and teeth numbers.

Intra-oral clinical photographic images are not currently required by Northeast Delta Dental on either predeterminations or claims.  However, the submission of intraoral clinical photographic images (pre-operative, intra-operative, and post-operative) for claims involving restorations or mucogingival surgery are extremely useful to the dental consultants, and can often increase the likelihood that your predetermination or claim will be favorably reviewed.  It will often decrease the likelihood that additional documentation will be requested.  Digital oral photography has become an integral part of many dental practices.  Please make every effort to submit photographic images (if available).

Periodontally involved teeth which would qualify for surgical pocket reduction benefits under these procedure codes must be documented to have at least 5 mm pocket depths and bone loss beyond 1-1.5 millimeters. If pocket depths are under 5 mm, then benefits are denied.

Code D7971 is to be used when inflammatory or hypertrophied tissue is being removed on a partially erupted or impacted tooth (i.e. operculectomy). Code D4211 is not the appropriate code for this procedure.

Code D4212 is a gingivectomy or gingivoplasty to allow access for a restorative procedure.

Please note that codes D4210, D4211 and D7971 performed on the same date of service as the preparation of a crown or other restoration is included in the fee for the restoration, and separate fees from the same dentist/dental office are not billable to the patient.

Upon request, claims submitted for gingivectomies may require additional clinical documentation to support a benefit determination. This may include pre-operative radiographic image, diagnostic and operative clinical notes, complete periodontal charting, and pre-operative photographic image (if available). 

The 2022 American Dental Association’s (ADA) descriptor of a core buildup (procedure code D2950) is:

“Core buildup, including any pins when required-Refers to building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure.  A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation.”

The procedure D2950 is benefitted when it is required to retain an indirectly fabricated restoration due to extensive loss of tooth structure due to caries or tooth fracture. Specifically, it is required when there is insufficient VERTICAL height to provide adequate resistance to displacement and retention of an extracoronally retained crown. A core buildup is generally indicated if all of the following criteria are met:

• A significant portion of the tooth structure (50% or more) is fractured or carious
• The preparation is at or below the gingival crest
• Less than 3mm of sound dentin remains coronal to the preparation line in opposing walls, where the crown margins will be located.

Upon request, claims submitted with code D2950 may require additional documentation.  This may include a current pre-operative radiograph image, pre-operative and inter-operative photographic image. (if available), and a legible copy of your clinical notes to include diagnosis, treatment provided, and prognosis.

Silver Diamine Fluoride is a medicament which arrests or inhibits carious lesions.  Per the American Dental Association (ADA), the appropriate code for the application of SDF or another similar acting medicament is CDT Code D1354 - Application of caries arresting medicament – per tooth. Northeast Delta Dental standardly covers code D1354 for primary and secondary teeth with no age restrictions, and may be benefitted twice per tooth in a twelve (12) month period. Please note that as of January 1, 2022, restorations will be denied when placed on the same tooth on the same day or within 60 days (used to be 90 days) after placing the caries arresting medicament. 

The American Dental Association’s (ADA) descriptor of code D9120 is:

“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. Includes all recontouring and polishing of retained portions.”

Code D9120 may be benefitted by Northeast Delta Dental when some portion of the fixed partial denture remains intact and serviceable after sectioning. Upon request, clinical documentation should include a pre-operative radiographic image showing the entire fixed partial denture, and clear documentation of the intended treatment plan in your legal clinical notes. If this procedure is part of the process of removing and replacing a fixed prosthesis, it is considered integral to the fabrication of the fixed prosthesis and a separate fee for this code is not billable to the patient.

Please note that code D9120 does not include sectioning splinted crowns (with no pontics).

Code D2980 should not be used when restoring an endodontic access opening unless there is restorative material failure beyond the opening, or when performing a restoration at the gingival margin of a crown. The more appropriate code is D2391 or D2140 (single surface restoration). Fees for crown repair are not billable to the patient within 24 months of the original restoration by the same dentist/dental office.  

2024 Northeast Delta Dental Dentist Handbook-General policies regarding specific codes. This resource can be accessed by logging in with your password to the secure side of the website; it is listed on the first page under “Documents.” 

The American Dental Association’s (ADA) 2024 Current Dental Terminology (CDT), and Coding Companion - Valuable resources in assisting your dental team in submitting the appropriate codes.