ADA Dental Code List Microsoft

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2021 ADA Code List for Microsoft Plans Use this list or our code check tool to confirm if pre-determination (pre-D) or Dental review is required. If more than one class is listed, refer to benefit details for the correct class or submit a pre-D. See PACAAR (PCM) ADA code list or non-individual employer groups ADA code list for all other Premera prefixes. KEY: Red: Authorization/documentation requirements Blue: Not covered services Grey: Deleted codes ADA Procedure Code Description Dental Review or Pre-D Documentation Required Class D0120 Periodic oral evaluation established patient N/A N/A Preventive D0140 Limited oral evaluation problem focused N/A N/A Preventive D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver N/A N/A Preventive D0150 Comprehensive o

D0120 Periodic oral evaluation – established patient N/A N/A Preventive D0140 Limited oral evaluation – ... (pathology or operative report if applicable) If submitting under medical, submit diagnosis or narrative. Medical policy 9.02.503 (Computerized Diagnostic Imaging for Complex Maxillofacial Procedures) Preventive D0365 Cone beam CT ...

  Oral, Pathology, Maxillofacial