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
DDPNJ = Delta Dental of New Jersey

ADA CDT-2005	Description	X-ray(s)	Perio Chart	Med EOB	Other
D4210	Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces, per quadrant		Yes		Narrative if more than 2 quadrants performed on same day
D4211	Gingivectomy or gingivoplasty - one to three contiguous teeth, or bounded teeth spaces, per quadrant		Yes		Narrative if more than 2 quadrants performed on same day
D4240	Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces, per quadrant		Yes		Narrative if implants are being performed. Narrative if more than 2 quadrants performed on same day
D4241	Gingival flap procedure, including root planing - one to three contiguous teeht or bounded teeth spaces, per quadrant		Yes		Narrative if implants are being performed. Narrative if more than 2 quadrants performed on same day
D4245	Apically positioned flap		Yes		Narrative if implants are being performed. Narrative if more than 2 quadrants performed on same day
D4249	Clinical crown lengthening - hard tissue	PA			Narrative
D4260	Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces, per quadrant	PA and/or FMX	Yes		Narrative if more than 2 quadrants performed on same day
D4261	Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces, per quadrant	PA and/or FMX	Yes		Narrative if more than 2 quadrants performed on same day
D4263-D4264	Bone replacement grafts	PA	Yes
D4265	Biologic materials to aid in soft and osseous tissue regeneration	PA	Yes		Narrative including type of material used
D4266-D4267	Guided tissue regeneration - per site	PA	Yes
D4268	Surgical revision procedure, per tooth	PA	Yes		Narrative
D4270-D4273	Soft tissue graft procedures		Yes		Narrative description of condition specify amount of attached gingiva
D4274	Distal or proximal wedge procedure		Yes
D4275	Soft tissue allograft		Yes		Narrative description of condition specify amount of attached gingiva
D4276	Combined connective tissue and double pedicle graft, per tooth		Yes		Narrative description of condition specify amount of attached gingiva
D4320-D4321	Provisional splinting	PA	Yes
D4341	Periodontal scaling and root planing - four or more teeth, per quadrant		Yes		Narrative if more than 2 quadrants performed on same day
D4342	Periodontal scaling and root planing - one to three teeth, per quadrant		Yes
D4381	Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report	PA DDPNJ requirement	Yes		Narrative including type of material used
D4910	Periodontal maintenance procedures		Yes if third prophy
D4999	Unspecified periodontal procedure, by report				Narrative