If there is an extenuating circumstance not evident from the documentation listed below, a narrative and any available corroborating diagnostics must be submitted. As part of the re-review process Delta Dental may require documentation (e.g. photographs) in addition to that listed in these charts.

All radiographs are pretreatment unless otherwise indicated. Any radiograph submitted must be of diagnostic quality and substantiate the need and appropriateness of the service submitted for predetermination or payment. In order to do so, the dentist may need to submit radiographs in addition to those listed in these charts.

All procedures listed on these charts are not necessarily covered benefits, and all benefits are not necessarily listed.

Unless otherwise noted:

Yes = Documentation Required
Blank = Documentation Not Required
PA = Periapical Radiograph (may require more than one for diagnostic purposes)
FMX = Full Mouth Series
Pano = Panorex
DDNJ = Delta Dental of New Jersey

ADA CDT-2005	Description	X-ray(s)	Perio Chart	Med EOB	Other
D6010-D6050	Implant services	PA, and/or FMX, and/or Pano			D6010 PA D6020 PA not required D6040 Pano D6050 Pano
D6053-D6079	Implant supported prosthetics	PA, and/or FMX, and/or Pano
D6080-D6090	Other implant services				Narrative
D6094	Implant supported prosthetics	PA, and/or FMX, and/or Pano
D6095-D6190	Other implant services				Narrative
D6194	Implant supported prosthetics	PA, and/or FMX, and/or Pano
D6199	Other implant services				Narrative
D6205-D6252	Fixed partial denture pontics	PA, and/or FMX, and/or Pano			Identify all missing teeth in both arches. Use tooth chart if available on claim form.
D6253	Provisional pontic	PA, and/or FMX, and/or Pano			Identify all missing teeth in both arches. Use tooth chart if available on claim form and narrative.
D6545-D6792	Fixed partial denture retainers - inlays/onlays & crowns. PAs not required for D6548	PA, and/or FMX, and/or Pano			Identify all missing teeth in both arches. Use tooth chart if available on claim form.
D6793	Provisional retainer crown	PA, and/or FMX, and/or Pano			Identify all missing teeth in both arches. Use tooth chart if available on claim form and narrative.
D6794	Titanium crown	PA, and/or FMX, and/or Pano			Identify all missing teeth in both arches. Use tooth chart if available on claim form.
D6970-D6972	Cast/prefabricated post and cores	PA
D6973	Core buildup for retainer, including any pins	PA
D6976-D6977	Each additional cast or prefabricated post - same tooth	PA
D6980	Fixed partial denture repair, by report				Narrative
D6999	Unspecified, fixed prosthodontic procedure, by report				Narrative