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Certificate of Insurance.

© Premier Access Insurance CompanyP.O. Box 659010

Sacramento, CA 95865-9010Phone (916) 920-2500 • Fax (916) 648-7748

PREMIER ACCESS INSURANCE COMPANY

DENTIST HANDBOOK

INTRODUCTION REVISED 05/09

NOTE: PLEASE REFER TO A PATIENT’S PREMIER CERTIFICATE OF INSURANCE TO DETERMINE

COVERED SERVICES AND SUPPLIES, EXCLUSIONS AND LIMITATIONS FOR AN INDIVIDUAL PATIENT.

A Word from the President

Dear Provider:

This Dentist Handbook is to help you and your staff understand PremierAccess Insurance Company’s dental benefit programs and the responsibilitiesof both Premier Access Insurance Company and the provider as it relates toservices provided to members. One of our primary goals in preparing thisDentist Handbook was to keep the information brief and simple.

I would like to thank you for participating in Premier Access InsuranceCompany’s provider network and encourage you to use this DentistHandbook as part of your office operations when treating Premier AccessInsurance Company’s members.Sincerely,

Reza Abbaszadeh, DDS

President and Chief Executive Officer

REVISED 05/09 TABLE OF CONTENTS



Important Contacts

Questions Can Be Answered By:Premier Provider Relations Department1-800-640-4466

Submit Claims To:Premier Access Insurance CompanyClaims DepartmentP.O. Box 659010Sacramento, CA 95865-9010

TABLE OF CONTENTS

TIPS ................................................................................................................................ 1

REQUIRED DOCUMENTATION ..................................................................................... 2

DIAGNOSTIC PROCEDURES (D0120 - D0999) ............................................................ 3

PREVENTIVE PROCEDURES (D1000 - D1999) ........................................................... 6

RESTORATIVE PROCEDURES (D2000 – D2999) ........................................................ 8

ENDODONTIC PROCEDURES (D3000 – D3999) ....................................................... 14

PERIODONTIC PROCEDURES (D4000 – D4999) ...................................................... 17

PROSTHODONTIC PROCEDURES (D5000 – D5899) ................................................ 22

MAXILLOFACIAL PROSTHETIC PROCEDURES (D5900 – D5999) ........................... 27

IMPLANT SERVICE PROCEDURES (D6000 – D6199) ............................................... 28

PROSTHODONTICS, FIXED (D6200 – D6999) ........................................................... 29

ORAL AND MAXILLOFACIAL SURGERY (D7000 - D7999) ......................................... 34

ORTHODONTICS (D8000 – D8999) ............................................................................ 42

ADJUNCTIVE GENERAL SERVICES (D9000 – D9999) .............................................. 44

You may visit our web site at www.premierppo.com

REVISED 05/09 1 DENTIST HANDBOOK TIPS



IMPORTANT NOTE

The coding and nomenclature listed in thismanual is to be considered definitive. Thecode you select to report treatmentshould, in all respects, accurately reflectthe procedure actually performed. It isfraud to misrepresent treatment on a pa-per or electronic claim by entering a codewhich does not accurately represent theprocedure actually provided.

TIPS

1. The fact that a dental procedure appears in this manualdoes not mean that it is covered by an eligible patient’sPremier group program. Please refer to the patient’sCertif icate of Insurance for detailed coverageinformation, including exclusions and limitations.

2. Coverage of pedodontic care is limited to children 14years of age and younger.

3. If you report treatment with a code number which is notlisted in this section, Premier will select the closestPremier code, based on the description of service onthe claim form.

4. Written notice of a claim must be given to Premier within30 days after the occurrence or commencement of anycovered service or supply, or as soon thereafter asreasonably possible, but no later than 180 days from thedate of service. Claims submitted more than 180 daysafter the date of service will not be considered for payment.

REQUIRED DOCUMENTATION 2 REVISED 05/09



REQUIRED DOCUMENTATION

Determining What Types ofDocumentation to Submit:If you’re unsure whether your claim should besubmitted with x-rays or charting, look for thefollowing symbols in this handbook.

P Complete periodontal charting, includingpocket depths, mobility, furcationinvolvements, missing teeth, gingivalrecession and mucogingival defects must besubmitted with claim.

X Pre-operative x-ray documentation (mounted)must be submitted with claim.

XX Pre-operative and post-operative x-raydocumentation (mounted) must be submittedwith claim.

A summary of the documentation requirements isshown to the right. On occasion, a Premier DentalConsultant may deem it necessary, given thecircumstances of a particular case, to requestx-rays for procedures that are not on this list.

RESTORATIVEX D1510-D1525 Space maintainer-fixed unilateral and bilateral,

removable unilateral and bilateralX D2335 Resin – four or more surfaces or involving incisal

(anterior)X D2510-D2652 Inlays/onlays – metallic, porcelain/ceramic;

composite/resinX D2710-D2810 Crowns – resin; castX D2960-D2962 Labial veneers

ENDODONTICSXX D3000-D3999 Root canals

PERIODONTICSP D4210-D4222 Gingivectomy or gingivoplastyPX D4240 Gingival flap procedure, including root planing –

per quadrantPX D4241 Gingival flap procedure, including root planing-

one to three teethX D4249 Clinical crown lengthening – hard tissuePX D4260 Osseous surgery – per quadrantPX D4261 Osseous surgery – one to three teeth in a

quadrantP D4270 Pedicle soft tissue graft procedurePX D4341 Periodontal root planing – per quadrantPX D4342 Periodontal root planing – one to three teeth in a

quadrant

PROSTHODONTICS, FIXEDX D6545 Retainer – cast metal for resin bonded fixed

prosthesisX D6750-D6792 Bridge retainers – crowns

ORAL SURGERYX D7210-D7250 Surgical removal of erupted/impacted tooth,

tooth rootsX D7260-D7281 Other surgical proceduresX D7450-D7461 Removal of odontogenic/nonodontogenic cyst or

tumorX D7471-D7490 Excision of bone tissueX D7540 Removal of foreign bodies – musculoskeletal

systemX D7550 Sequestrectomy for osteomyelitisX D7560 Maxillary sinusotomyX D7610-D7680 Simple fracturesX D7710-D7780 Compound fracturesX D7940-D7949 Osteoplasty/osteotomy/LeFort I, II and IIIX D7971 Excision of pericoronal gingivaX D7980-D7981 Sialolithotomy/excision of salivary gland

REVISED 05/09 3 DIAGNOSTIC PROCEDURES (D0100 - D0999)

- SUBMIT PRE-OPERATIVE X-RAYS FOR PROCEDURES MARKED “X” -



GuidelinesORAL EXAMINATIONS –GENERAL GUIDELINES1. The purpose of any patient as-sessment that may includegathering of information throughinterview, observation and exami-nation is to formulate a properdiagnosis and treatment plan. Nodistinctions are made betweendisciplines.

PROCEDURE D0120

Periodic oral evaluation.

PROCEDURE D0140

Limited oral evaluation-problemfocused.

1. This procedure is an evaluationor re-evaluation limited to aspecific oral health problem.

2. Limited oral exams (emergencyoral exams), considered forpayment as a separate benefitonly if no other treatment (exceptx-rays) is rendered during thevisit.

PROCEDURE D0145

Oral evaluation for a patient underthree years of age and counselingwith primary caregiver.

PROCEDURE D0150

Comprehensive oral evaluation-new or established patient.

1. Premier considers comprehen-sive oral evaluation to apply to thedentist’s/dental office’s first en-counter with a new patient.Subsequent submissions ofD0150 will be considered to be theequivalent of procedure D0120,periodic oral evaluations.

PROCEDURE D0170

Re-evaluation-limited, problemfocused (established patient; notpost-operative visit.

PROCEDURE D0180

Comprehensive peridontal evalu-ation-new or established patient.

RADIOGRAPHS –GENERAL GUIDELINES1. Page 3 of this handbook iden-tifies each procedure for whichpre-operative x-ray documenta-tion is requested (proceduresrequiring submission of x-rays aremarked with an X).

2. In general, you should submitpre-operative x-rays, of diagnos-tic quality, for review by Premier’sconsultant staff for the proce-dures marked in that manner.Occasionally a consultant will re-quest submission of other films toclarify a specific case.

3. Film procedures includeexamination and diagnosis.

4. The accepted fee for acomplete intraoral series (D0210)is the maximum amount payablefor any combination of intraoral x-rays performed in a singletreatment series.

5. X-rays should be mounted andsecured to the Attending Dentist’sStatement. The patient’s nameand dentist’s license numbershould be indicated on themounting.

6. X-ray films will not be returnedto the dental office, unless spe-cifically requested at the time ofsubmission. The dental officeshould maintain a copy of thex-ray films in the original patientrecord. Premier is not respon-sible for lost x-ray films. If youare returning a notice of prior-au-thorization to Premier forpayment, you do not need to re-submit the x-rays unless you havemade changes to, or additions to,the treatment plan.

7. Please do not send films toPremier separately from atreatment form except:

a. when specifically requestedby a Premier consultant; or

b. when you are asking forreevaluation. If you forget toenclose x-rays when yousubmit the attending Dentist’sStatement, please wait forPremier to request them.

DIAGNOSTIC PROCEDURES (D0120 - D0999)

DIAGNOSTIC PROCEDURES(D0100 - D0999) 4 REVISED 05/09




PROCEDURE D0210

Intraoral – complete series(including bitewings).

1. This service is limited in mostPremier programs to onecomplete series in a five-yearperiod.

2. A complete series consists ofa set of intraoral radiographsusually consisting of 14 to 22periapical and posterior bitewingimages intended to display thecrowns and roots of all teeth,periapical areas, and alveolarbone.

3. A panoramic film taken inconjunction with a completeintraoral series is not a separatebenefit.

PROCEDURE D0220

Intraoral – periapical — firstfilm.

PROCEDURE D0230

Intraoral – periapical – eachadditional film.

PROCEDURE D0240

Intraoral – occlusal film.

PROCEDURE D0250

Extraoral – first film.

PROCEDURE D0260

Extraoral – each additional film.

PROCEDURE D0270

Bitewings – single film.

PROCEDURE D0272

Bitewings – two films.

PROCEDURE D0273

Bitewings –three films.

PROCEDURE D0274

Bitewings – four films.

PROCEDURE D0277

Vertical bitewings - 7 to 8 films.

PROCEDURE D0330

Panoramic film.

1. A panoramic film taken inconjunction with a completeintraoral series is not a separatebenefit.

ORAL PATHOLOGYLABORATORY

PROCEDURE D0472

Accession of tissue, grossexamination, preparation andtransmission of written report.

1. Please attach the laboratoryreport to the claim.

PROCEDURE D0473

Accession of tissue, gross andmicroscopic examination, prepa-ration and transmission of writtenreport.


PROCEDURE D0474

Accession of tissue, gross andmicroscopic examination, includ-ing assessment of surgicalmargins for presence of disease,preparation and transmission ofwritten report.


PROCEDURE D0475

Decalcification procedure.

1. Premier considers thisprocedure to be inclusive of otherpathology reports and procedure(D0502).

PROCEDURE D0476

Special stains for microorganisms.


PROCEDURE D0477

Special stains, not formicroorganisms.


REVISED 05/09 5 DIAGNOSTIC PROCEDURES (D0100 - D0999)




PROCEDURE D0478

Immunohistochemical stains.


PROCEDURE D0479

Tissue in-situ hybridization,including interpretation.


PROCEDURE D0481

Electron microscopy —diagnostic.


PROCEDURE D0482

Direct immunofluorescence.


PROCEDURE D0483

Indirect immunofluorescence.


PROCEDURE D0484

Consultation on slides preparedelsewhere.

1. When this procedure isreported, Premier will base theallowance on D9310. The eligiblepatient can not be balance billed.

PROCEDURE D0485

Consultation, includingpreparation of slides from biopsymaterial supplied by referringsource.

1. Please submit a copy of thepathology report.

2. When procedure D0485 isreported, Premier’s consultantstaff will determine the allowanceby determining whether grossexamination, gross andmicroscopic examination, or grossand microscopic examinationincluding the assessment ofsurgical margins was performedin evaluation of the tissue sample.

PROCEDURE D0502

Other oral pathology procedures,by report.

1. Please provide a detaileddescription of the procedure orprocedures performed.

PROCEDURE D0999

Unspecified diagnosticprocedure, by report.

1. Please enter a completedescription of services on theAttending Dentist’s Statement.

PREVENTIVE PROCEDURES (D1000 - D1999) 6 REVISED 05/09




PREVENTIVE PROCEDURES (D1000 - D1999)

GuidelinesPROPHYLAXIS ANDFLUORIDE TREATMENT -GENERAL GUIDELINES1. Benefits are limited to one pro-phylaxis, peridontal maintenance,or full mouth debridement and/orfluoride treatment in a 6-monthperiod in most Premier programs.Some group purchasers havecontracted for different limitations.Additional treatments are thepatient’s responsibility.

2. The use of fluoride or othermedicaments for desensitizationshould be listed on the AttendingDentist’s Statement as procedureD9910. The use for microbialcontrol should be listed as pro-cedure D1999. The use for homecare should also be listed as pro-cedure D1999. These proce-dures are not benefits of Premierprograms, and any fees are thepatient’s responsibility.

3. When Prophylaxis and Fluoridetreatment are completed on thesame date of service, paymentwill be combined to allow for themaximum benefit under thepolicy.

DENTAL PROPHYLAXISRemoval of plaque, calculus andstains from the tooth structure. Itis intended to control irritationalfactors.

PROCEDURE D1110

Prophylaxis - adult.

PROCEDURE D1120

Prophylaxis- child to age 14.

TOPICAL FLUORIDETREATMENT (OFFICEPROCEDURE)

PROCEDURE D1203

Topical application of fluoride(excluding prophylaxis) - child toage 14.

PROCEDURE D1204

Topical application of fluoride(excluding prophylaxis) - adult.

PROCEDURE D1206

Topical fluoride varnish;therapeutic application formoderate to high caries riskpatients.

OTHER PREVENTIVESERVICES

PROCEDURE D1351

Sealant – per tooth.

1. Pit and fissure sealants arebenefits of most Premierprograms.

2. When sealants are covered,they are payable as Basicbenefits. Programs that includesealants generally l imit thebenefit to permanent, non-carious, unrestored first andsecond molars to age 14. Ifotherwise provided, the patient isresponsible for the fee.

3. Please enter the tooth number,surface and a separate fee foreach sealant provided onindividual lines of the AttendingDentist’s Statement.

4. The provision of sealantsunder a Premier programincludes any reapplication withina three year period.

PROCEDURE D1352

Preventive resin restoration

1. This procedure is forconservative restoration of anactive cavitated lesion in a pit orfissure that does not extend intodentin; includes placement of asealant in any radiating non-carious fissures or pits.

REVISED 05/09 7 PREVENTIVE PROCEDURES (D1000 - D1999)




2. When preventive resinrestorations are covered, they arepayable as Basic benefits.Programs that include preventiveresin restorations, generally limitthe benefit to permanent, non-carious, unrestored first andsecond molars to age 14. Ifotherwise provided, the patient isresponsible for the fee.

3. Please enter the tooth numberand surface.

4. The provision of preventiveresin restoration under a Premierprogram includes anyreapplication within a three yearperiod, including application orreapplication of sealants.

5. Not a benefit in conjunctionwith other restorative treatments.

SPACE MAINTENANCE(PASSIVE APPLIANCES)

PROCEDURE D1510 - X

Space maintainer – fixedunilateral.

1. When space maintainers arecovered, they are payable asbasic benefits.

2. Please indicate the spacebeing maintained by identifyingthe quadrant in the columnmarked “tooth number” with anabbreviation (UR, UL, LR, LL).

PROCEDURE D1515 - X

Space maintainer – fixedbilateral.

1. When space maintainers arecovered, they are payable asbasic benefits.

2. Please indicate the spacesbeing maintained by identifyingthe arch in the “tooth number”column with an abbreviation (U orL).

PROCEDURE D1520 - X

Space maintainer – removableunilateral.

1. Benefit only when the groupprogram includes orthodonticcoverage.

2. Please indicate the location ofthe space being maintained byidentifying the quadrant in the“tooth number” column with anabbreviation (UR, UL, LR, LL).

PROCEDURE D1525 - X

Space maintainer – removablebilateral.

1. Benefit only when the groupprogram includes orthodonticcoverage.

2. Please indicate the spacesbeing maintained by identifyingthe arch in the “tooth number”column with an abbreviation (U orL).

PROCEDURE D1999

Unspecified preventiveprocedure, by report.

1. Please enter a completedescription of the service andclinical reason on the AttendingDentist’s Statement.

RESTORATIVE PROCEDURES (D2000 - D2999) 8 REVISED 05/09




GuidelinesRESTORATIVE – GENERALGUIDELINES1. When the restoration is ofamalgam or resin, the toothsurface(s) must be identified onthe Attending Dentist’s Statementin the column marked “surfaces.”Please use the followingabbreviations:

B buccal

D distal

F facial or labial

I incisal

L lingual

M mesial

O occlusal

2. Multiple fillings performed onthe same day on the same toothsurface will be combined into 1surface (e.g. MO and DO = MOD).

3. Restorations which areprovided because of attrition,abrasion, erosion, wear, or forcosmetic purposes are thefinancial responsibility of thepatient under most programs.

4.Verified mercury allergies are abenefit. The removal of amalgamand replacement with resin will becovered with the proper docu-mentation. Allowance for resinswill be based on the amalgam al-lowance.

5. Replacement of amalgam orresin restorations in less than 12months for patients up to age 19and 36 months for patients 19 andover by the same dentist or by a

RESTORATIVE PROCEDURES (D2000 – D2999)

dentist at the same location is notchargeable to Premier or to thepatient except in extraordinarycircumstances involving externalviolent and accidental means,recurrent caries or radiationtherapy.

6. Fees for restorations includedirect pulp capping (seeprocedure D3110 for additionalinformation) and any materialplaced in a tooth as a base (orconstrued to be a base). Aseparate allowance for indirectpulp capping is made forexposure or near exposure of thepulp, and only in thecircumstances described in theexplanation of procedure D3120.

7 . Occlusal correction isconsidered to be inclusive of therestorative procedure.

8. The term “anterior” refers to theincisors and cuspids. “Posterior”refers to bicuspids and molars.

AMALGAMRESTORATIONS(INCLUDING POLISHING)

PROCEDURE D2140

Amalgam — one surface,primary or permanent.

PROCEDURE D2150

Amalgam — two surfaces,primary or permanent.

PROCEDURE D2160

Amalgam — three surfaces,primary or permanent.

PROCEDURE D2161

Amalgam — four or moresurfaces,primary or permanent.

RESIN BASEDCOMPOSITERESTORATIONS

PROCEDURE D2330

Resin-based composite — onesurface, anterior.

1. This procedure involves asingle restoration on anteriorteeth, which does not involve theincisal angle. For resinrestorations on posterior teeth,please see procedures D2391through D2394.

2. Proximal restorations inanterior teeth which do notinvolve the incisal angle (a DLrestoration, for example) areconsidered single surfacerestorations. If the incisal angleis involved, see procedureD2335.

3. Two separate restorations,such as a facial and lingualrestorations on the same tooth,on the same date of service willbe considered as one restorationwith two or more surfaces.

REVISED 05/09 9 RESTORATIVE PROCEDURES (D2000 - D2999)




4. The fee is considered toinclude all materials ortechniques associated withplacing the restoration.

PROCEDURE D2331

Resin-based composite — twosurfaces, anterior.





PROCEDURE D2332

Resin-based composite — threesurfaces, anterior.





PROCEDURE D2335 - X

Resin-based composite — fouror more surfaces or involvingincisal angle (anterior).

1. This is a class IV restoration.The restoration replaces one orboth incisal angles of an anteriortooth. When the incisal angle isnot involved, use procedureD2330.


PROCEDURE D2390 - X

Resin-based composite crownanterior.

PROCEDURE D2391

Resin-based composite — onesurface, posterior.

PROCEDURE D2392

Resin based composite — twosurfaces, posterior.

PROCEDURE D2393

Resin-based composite — threesurfaces, posterior.

PROCEDURE D2394

Resin-based composite — fouror more surfaces, posterior.

INLAYS, ONLAYS,CROWNS – GENERALGUIDELINES1. A crown is a benefit when atleast four or more surfaces of theteeth have defects and at leastone cusp is undermined (In caseof anterior teeth, the incisal anglemust be undermined).

2. Premier programs provide forthe maximum allowance for basemetal crowns. The fee forprecious metal is the patient’sresponsibility.

3. Prior authorization isrequired for all cast restorations.

4. Crowns, jackets and castinlays and onlays are a benefitonce in a five-year period forpatients 16 years of age or olderin most Premier programs.





5. Crowns on anterior teeth arenot a benefit for children under 16years of age. Premier may makean allowance for a prefabricatedcrown.

6. Premier considers thefollowing inclusive: occlusaladjustment, temporaries, pulpcaps / bases, build-ups, andgingivectomy / gingivoplasty.

7. A cast restoration is only abenefit when the tooth cannot berestored with an amalgam or resinrestoration. If the tooth can berestored with an amalgam or resinrestoration any cast restoration isoptional. Premier will make an al-lowance for the correspondingamalgam or resin restoration.

8. Restorations which are pro-vided because of attrition, abra-sion, erosion, wear or for cos-metic purposes are consideredoptional services, and are the fi-nancial responsibility of the pa-tient.

9. Provision of crowns includesany recementation or repair bythe same dental office withintwelve months.

10. Premier has adopted thesystem of classification andnomenclature for castrestorations set forth by theAmerican Dental Association. The“noble metal” classificationsystem permits a precise methodof reporting various alloys usedin fabricating the cast restoration,based on the percentage byweight of metals from the gold(Au) and platinum (Pt) groups.

11. In the “date serviceperformed” column of theAttending Dentist’s Statement,indicate the date the crown, jacketor cast inlay was permanentlycemented. Impression datesshould not be indicated unlessspecifically requested by Premier.

INLAY / ONLAYRESTORATIONS

PROCEDURE D2510 - X

Inlay – metallic – once surface.

1. Premier programs provide foramalgam restorations fortreatment of caries if the tooth canbe restored with such material. Insuch cases a metallic inlay isconsidered optional, and the feeis the responsibility of the patient.Premier may make an allowancefor an amalgam restoration.

PROCEDURE D2520 - X

Inlay – metallic – two surfaces.

1. See procedure D2510, item2.

2. Porcelain/ceramic inlays andonlays are not a benefit of mostPremier programs. Premier maymake an allowance toward theircost based on the cost for thecorresponding amalgamrestoration or metallic inlay oronlay, and the patient isresponsible for the remainder ofthe fee.

PROCEDURE D2530 - X

Inlay – metallic – three or moresurfaces.

1. This procedure is consideredto involve the restoration of threeor more surfaces.

2. See procedure D2510, item 2.

PROCEDURE D2542 - X

Onlay - metallic - two surfaces.

PROCEDURE D2543 - X

Onlay - metallic - three surfaces.

PROCEDURE D2544 - X

Onlay - metallic - four or moresurfaces.

CROWNS – SINGLERESTORATION ONLY(See general guidelines forinlays, onlays and crowns,page 19.)

PROCEDURE D2710 - X

Crown – resin (laboratory).

1. Inclusive of the fee for thecompleted restoration when usedas a temporary.

2. “Plastic” or “polycarbonate”crowns of a permanent nature,routinely used for a child’sfractured anterior tooth, should beindicated as procedure D2932.





PROCEDURE D2712 - X

Crown—3/4 resin-basedcomposite (indirect).

1. Please see the guidelines forprocedure D2710.

PROCEDURE D2720 - X

Crown — resin with high noblemetal.

PROCEDURE D2721 - X

Crown — resin withpredominantly base metal.

PROCEDURE D2722 - X

Crown — resin with noble metal.

PROCEDURE D2740 - X

Crown – porcelain/ceramicsubstrate.

PROCEDURE D2750 - X

Crown – porcelain fused to highnoble metal.

1. Procedure D2750 is for asingle restoration only. Pleaseuse procedure D6750 if thecrown is part of a fixed prostheticappliance.


PROCEDURE D2751 - X

Crown – porcelain fused topredominantly base metal.

1. Procedure D2751 is for a singlerestoration only. Please useprocedure D6751 if the crown ispart of a fixed prostheticappliance.

PROCEDURE D2752 - X

Crown – porcelain fused tonoble metal.



PROCEDURE D2780 - X

Crown — 3/4 cast high noblemetal.

1. Premier programs provide forthe maximum allowance for basemetal crowns. The fee for preciousmetal is the patient’s responsibility.

PROCEDURE D2781 - X

Crown — 3/4 cast predominantlybase metal.

PROCEDURE D2782 - X

Crown — 3/4 cast noble metal.


PROCEDURE D2783 - X

Crown — 3/4 porcelain/ceramic.

PROCEDURE D2790 - X

Crown — full cast high noblemetal.



PROCEDURE D2791 - X

Crown — full cast predominantlybase metal.






PROCEDURE D2792 - X

Crown — full cast noble metal.



OTHER RESTORATIVESERVICES

PROCEDURE D2910

Recement inlay.

1. Please indicate the toothnumber on the Attending Dentist’sStatement.

2. Premier considers fees forrecementation to be included inthe cost of covered restorations for12 months following initialplacement. During this period, aseparate fee for recementation isnot chargeable.

PROCEDURE D2915 - X

Recement cast or prefabricatedpost and core.


2. When D2915 is reported inconjunction with D2920(Recement crown), Premierconsiders D2915 to be part of,and included in the fee for,D2920.

3. Premier considers fees forrecementation to be included inthe cost of covered restorationsfor 12 months following initialplacement. During this period, aseparate fee for recementation isnot chargeable.

PROCEDURE D2920

Recement crown.


2. Premier considers fees forrecementation to be included inthe cost of covered restorationsfor 12 months following initialplacement. During this period, aseparate fee for recementationis not chargeable.

PROCEDURE D2930

Prefabricated stainless steelcrown - primary tooth.

1. There is a 3 year limitation onreplacement of a prefabricatedstainless steel crown by the samedentist/dental office.

PROCEDURE D2931

Prefabricated stainless steelcrown - permanent tooth.

1. Under Premier’s processingpolicies; this procedure is not acovered benefit for members age19 years old and over. Allowancemay be made for thecorresponding amalgam(4 surfaces or more).

PROCEDURE D2932

Prefabricated resin crown.

1. When a resin crown is used asa temporary restoration while thefinal restoration is beingfabricated, it is considered in thefee for the completed restoration.

2. When resin crowns areprovided on children, “plastic” or“polycarbonate” crowns of apermanent nature, routinely usedfor a fractured anterior tooth untila porcelain or other permanentrestoration can be placed, shouldbe indicated as procedure D2932.

PROCEDURE D2950

Core buildup, including any pins.

1. A build up under a crown is nota benefit. It is included in the feefor the crown.

PROCEDURE D2951

Pin retention - per tooth, inaddition to restoration.

1. This procedure is for pinretention, per tooth, whennecessary and when the finalrestoration is amalgam or resin.

2. Please indicate the toothnumber and the fee on theAttending Dentist’s Statement ona separate line from the amalgamor resin restoration.

3. The fee is considered to applyper tooth, regardless of thenumber of pins placed.





PROCEDURE D2952

Cast post and core in addition tocrown.

1. This procedure code appliesto an individually fitted andcustom cast post (including acore and coping) that isnecessary for placement forendodontically treated toothrequiring a crown.

2. When the post is prefabri-cated, use procedure D2954.

3. As defined, the fee includesthe post and any core (buildup/substructure).

4. Premier allows for one castpost and core per tooth. Aseparate fee is not chargeable tothe patient.

PROCEDURE D2954

Prefabricated post and core inaddition to crown.

1. This procedure applies tocommercial preformed post of anymaterial or shape for placementinto the endodontically treatedcanal for support.

2. As defined, the fee includes thepost and any core (buildup/substructure).

PROCEDURE D2960 - X

Labial veneer (laminate) -chairside.

1. Indicate the surface(s) restored.

2. The in-office application of adental laminate with directmaterials is a benefit only onpermanent, anterior teeth, and isconsidered to be a Basicprocedure, subject to all of thesame limitations and exclusionsas other anterior restorations.

3. Premier may make anallowance for the correspondingone surface resin restoration.

4. Prior-authorization is required.

PROCEDURE D2962 - X

Labial veneer (porcelainlaminate) - laboratory.

1. Laminate / partial crowns arebenefits only on permanent,anterior teeth, subject to all of thelimitations and exclusions forcrowns (see Crowns - GeneralGuidelines). When provided forcosmetic purposes or to restorestructure loss from wear, attritionor erosion; they are consideredoptional treatment. The fee is thepatient’s responsibility.

2. Laminate / partial crowns arenot benefits as abutments of acid-etch retained bridges.

3. Prior-authorization is required.

PROCEDURE D2980

Crown repair, by report.

1. Please write a report on theAttending Dentist’s Statement ofthe nature of the repair. Theallowance will be determined afterevaluation by the Premierconsultant staff.

PROCEDURE D2999

Unspecified restorativeprocedure, by report.

1. Please enter a completedescription of service and clinicalreason on the Attending Dentist’sStatement.

ENDODONTIC PROCEDURES (D3000 - D3999) 14 REVISED 05/09




GuidelinesPULP CAPPING

PROCEDURE D3110

Pulp cap - direct (excluding finalrestoration).

1. Direct pulp capping isconsidered to be part of, andincluded in the fee for, therestoration.

2. Cement bases are included inthe fee for restorations.

PROCEDURE D3120

Pulp cap - indirect (excluding finalrestoration).

1. All applications of indirect pulpcapping are considered part of,and included in the fee for, therestoration.

PULPOTOMY

PROCEDURE D3220

Therapeutic pulpotomy(excluding final restoration).

1. This procedure is consideredpart of, and included in the fee forthe complete endodontictreatment.

2. This is not a benefit for adults.If no other treatment is provided,this is payable as procedureD9110.

3. This procedure is covered onlywhen no other services areprovided on the same date ofservice, except x-rays. Thisprocedure is payable as Palliativetreatment, procedure D9110.

PROCEDURE D3221

Pupal debridement , primary andpermanent teeth.

1. This procedure is consideredpart of, and included in the fee for,the complete endodontictreatment.

2. This is not a benefit for adults.If no other treatment is provided,this is payable as procedureD9110.

3. This procedure is covered onlywhen no other services areprovided on the same date ofservice, except x-rays. Thisprocedure is payable as Palliativetreatment, procedure D9110.

ENDODONTIC THERAPYON PRIMARY TEETH

PROCEDURE D3230

Pupal therapy (resorbablefilling) -anterior, primary tooth(excluding final restoration.)

PROCEDURE D3240

Pulpal therapy (resorbable filling)- posterior, primary tooth(excluding final restoration).

ROOT CANAL THERAPY(INCLUDING TREATMENTPLAN, CLINICALPROCEDURES, ANDFOLLOW-UP CARE)

ROOT CANAL THERAPY-GENERAL GUIDELINES1. Test films taken as part of rootcanal therapy are considered partof, and included in the fee for, thecomplete endodontic procedure.

2. The initial opening into thecanal and routine post-operativevisits are considered part of, andincluded in the fee for, completeendodontic treatment.

3. In the date of service columnof the Attending Dentist’sStatement, please indicate thedate that the endodontictreatment was completed.Incomplete endodontic treatmentis not a benefit of Premierprograms.

4. A final x-ray must be submittedwith the claim to determinebenefits. A Pre-operativeperiapical fi lm and a Post-operative periapical film arerequired to determine benefits forRe-treatment of root canaltherapy.

5. Premier and the patient are notresponsible for payment towardunacceptable root canalprocedures.

6. An acceptable root canaltreatment is one that the final filmindicates a dense filling of theapical 1/3 within 1.5 mm of theapex of each root.

ENDODONTIC PROCEDURES (D3000 – D3999)

REVISED 05/09 15 ENDODONTIC PROCEDURES (D3000 - D3999)




7. When root canal is performedon a primary tooth, it will bereviewed by a Premier Consultantto determine allowance; generallyit will be paid as a pulpotomy.

8. Endodontic re-treatment bythe same dentist/dental officewithin 24 months is included inthe cost off the initial root canal.

9. Root canal procedures due tothe fabrication of over denturesare the patient’s financialresponsibility.

PROCEDURE D3310 - XX

Root canal therapy - anterior(excluding final restoration).


Root canal therapy - bicuspid(excluding final restoration).


Root canal therapy - molar(excluding final restoration).

PROCEDURE D3331

Treatment of root canalobstruction; non-surgical access.

1. Please describe the nature andduration of the treatment.

PROCEDURE D3332

Incomplete endodontic therapy;inoperable, unrestorable orfractured tooth.

1. Premier considers procedureD3332 to be the equivalent ofprocedure D9110. Claims foradditional allowances due toextraordinary circumstances willbe individually evaluated byPremier’s consultant staff. Theconsultant will base his or herdetermination on the documen-tation submitted with the claim.


Internal root repair of perforationdefects.

1. Premier considers procedureD3333 to be the equivalent ofprocedure D3351.

ENDODONTICRETREATMENT


Retreatment of previous rootcanal therapy - anterior.


Retreatment of previous rootcanal therapy - bicuspid.


Retreatment of previous rootcanal therapy - molar.

APEXIFICATION/RECALCIFICATIONPROCEDURES

PROCEDURE D3351 - X

Apexification/recalcif ication/pulpal regeneration – initial visit(apical closure/calcific repair ofperforations, root resorption, pulpspace, disinfection, etc.).

1. This procedure includesopening tooth, preparation ofcanal spaces, first placement ofmedication and necessaryradiographs.

2. This procedure may includefirst phase of complete root canaltherapy.

PROCEDURE D3352

Apexification/recalcif ication/pulpal regeneration – interimmedication replacement (apicalclosure/calcific repair ofperforations, root resorption, pulpspace, disinfection, etc.).

1. This Procedure is for visits inwhich the intra-canal medicationis replaced with new medicationand necessary radiographs.


Apexification / recalcification -final visit (includes completedroot canal therapy - apicalclosure / calcific repair ofperforations, root resorption,etc.)

ENDODONTIC PROCEDURES (D3000 - D3999) 16 REVISED 05/09





Pulpal regeneration- (completionof regenerative treatment in animmature permanent tooth withnecrotic pulp); does not includefinal restoration.

1. This procedure includesremoval of intra-canal medicationand procedures necessary toregenerate continued rootdevelopment and necessaryradiographs. This procedureincludes placement of a seal atthe coronal portion of the rootcanal system.

2. Requires completion ofregenerative treatment ofimmature permanent tooth.

3. Submission of diagnosticradiographs.

4. When pulpal regenerations arecovered, they are benefit once inlifetime.

5. Not a benefit in conjunction withD3351, D3352 and D3353.

APICOECTOMY/PERIRADICULARSERVICES


Apicoectomy/periradicularsurgery - anterior.

1. This service is defined as theexcision of the apical portion ofthe root of a previouslyendodontically treated anteriortooth to remove diseasedperiapical tissue.

2. This service is considered partof, and included in the fee for,osseous surgery (procedureD4260).

3. For retrograde filling, seeprocedure D3430.


Apicoectomy/periradicularsurgery - bicuspid (first root).

1. This service is defined as theexcision of the apical portion ofthe root of a previouslyendodontically treated bicuspid toremove diseased periapicaltissue.



4. For additional roots, seeprocedure D3426.


Apicoectomy/periradicularsurgery - molar (first root).

1. This services is defined as theexcision of the apical portion ofthe root of a previouslyendodontically treated molar toremove diseased periapicaltissue.



4. For additional roots, seeprocedure D3426.


Apicoectomy/periradicularsurgery (each additional root).


Retrograde filling - per root, inaddition to Apicoectomy/periradicular surgery.


Root amputation - per root.


PROCEDURE D3460 - X

Endodontic endosseous implant.

1. Procedure D3460 describes asmooth and/or threaded pinimplant which extends throughthe root canal into periapical boneto stabilize a mobile tooth.

2. Authorization is required.Premier will not pay for implantprocedures which are providedwithout obtaining the requiredauthorization.

3. See “Implants - generalguidelines” in this section of thehandbook.

4. Implants are not benefits ofmost Premier programs.

REVISED 05/09 17 PERIODONTIC PROCEDURES (D4000 - D4999)




SURGICAL SERVICES(INCLUDING USUAL POST-OPERATIVE SERVICES1. Surgical services include 3months of post-opertive care andsurgical re-entery for 3 years.

PROCEDURE D4210 - PX

Gingivectomy or gingivoplasty -four or more contiguous teeth orbounded teeth spaces perquadrant.

1. These surgical procedures aredirected at correction of the softtissue around the tooth. Gingivec-tomy is the excision of the soft tis-sue wall of the periodontal pocketwhen the pocket is uncomplicatedby extension into the underlyingbone. Gingivoplasty is the pro-cedure by which gingival deformi-ties (particularly enlargements)are reshaped and reduced to cre-ate normal and functional form.Procedure D4210 is consideredto include any frenectomy per-formed in the same area on thesame case.

2. Root planing is considered tobe included in the fee for thesurgery if not performed at least4 weeks before surgery.

3. Please submit completeperiodontal charting. Requiresat least 6 mm pockets, and earlybone loss. 5mm pockets may beconsidered in conjunction with 6mm or more pockets in the samequadrant. Use the tooth chart onthe Attending Dentist’s Statementto indicate missing teeth, circlingthe surgical area(s).

PERIODONTIC PROCEDURES (D4000 – D4999)

Periodontics - GeneralGuidelines1. Premier’s periodontal reportingguidelines are designed to assistyou in submitting cases and inunderstanding the periodontalbenefits available in most Premierprograms. These reportingguidelines require that cases beidentified by periodontal charting.For each specific treatment,procedures are generally payableand contractual limitations apply.

2. Proper documentation isespecially important in the caseof periodontal services. Pleasereview the recommendeddocumentation which ispresented in the following pagesunder each procedure code.

3. Site is defined as up to twoadjacent teeth with contiguoustissue for guided tissueregeneration, soft tissue gingivalgrafts, and crown lengthening.

4. Periodontal services are avail-able only when performed onnatural teeth for treatment ofperiodontal disease with theexception of clinical crownlengthening. When used in con-junction with implants, ridgeaugmentation, extraction sites,periradicular surgery, etc. the feeis the patient’s responsibility.

5. Preauthorization is recom-mended.

6. Periodontal proceduresperformed for cosmetic reasonsare the patient’s responsibility.

4. Gingivectomy provided inassociation with the preparationof a crown or other restoration isincluded in the fee for therestoration.


Gingivectomy or gingivoplasty -one to three contiguous teeth orbounded teeth spaces perquadrant.

1. Please submit completeperiodontal charting.

2. Please see the guidelines forprocedure D4210 for guidelines.


Gingival flap procedure,including root planing-perquadrant - four or morecontiguous teeth or boundedteeth spaces per quadrant.

1. Please submit completeperiodontal charting. Requiresat least 5 to 6 mm pockets, andearly bone loss.

2. The gingival flap procedurefacilitates access via resectionand retraction of a soft tissue flap.When different periodontalsurgical procedures are providedin any 36-month period in thesame quadrant, the totalapproved (benefits) will be basedupon the full quadrant fee for the“most inclusive procedure.”

3. Procedure D4240 isconsidered to include anyfrenectomy performed in thesame area on the same date.

PERIODONTIC PROCEDURES (D4000 - D4999) 18 REVISED 05/09




4. Procedure D4240 cannot bebilled on the same date asprocedures D1110, procedureD4341, or procedure D4910.

5. Since surgical re-entry isincluded for three years,procedure D4240 would generallynot be used preceding orfollowing other periodontalsurgical procedures on the sameteeth.

6. By definition, procedure D4240includes root planing andtherefore would not precede non-surgical root planing, perquadrant.

7. Periodontal root planingusually would not be performeduntil 36 months after surgery inthe same area.


Gingival flap procedure,including root planing — one tothree contiguous teeth orbounded teeth spaces perquadrant.


PROCEDURE D4249 - X

Clinical crown lengthening –hard tissue.

1. Please submit a narrativereport. Indicate the tooth or teethinvolved. The allowance will bedetermined following review bythe Premier consultant staff.

2. This procedure is carried outto expose sound tooth structure,facilitating restorative proce-dures. It usually includes both softand hard tissue removal.

3. Preparation involving only softtissue prior to placing a crown orother restoration is considered tobe included in the fee for therestoration.

4. Crown lengthening forcosmetic purposes or to correctcongenital or developmentaldefects is not a benefit of Premierprograms. The fee is the patient’sresponsibility.

5. When performed in conjunctionwith other osseous periodontalsurgery, crown lengthening isconsidered part of, and includedin the fee for, the more inclusivesurgery.

6. Allowances for this procedureare made by site. Please see thedefinition of “site” at the beginningof this periodontal section.


Osseous surgery (including flapentry and closure) – four or morecontiguous teeth or boundedteeth spaces per quadrant.

1. Please submit completeperiodontal charting. Requirescomplete periodontal chartingwhich indicate pockets in therange of 6 mm and above, andmoderate to severe bone loss.

2. The purpose of this periodon-tal surgery is to gain access toclean the roots of the teeth andto eliminate the pockets by meansof eradication or new attachment.The implication in this procedureis that having made a flap entry,the dentist will complete all pro-cedures necessary to achievethat purpose. Therefore, any os-seous contouring, including re-

moval of exostosis, hemi-sec-tions, extractions, root amputa-tions, frenectomy, and root plan-ing are considered and includedprocedures under code D4260. Ifthere is a combination of proce-dures in one quadrant (e.g. buc-cal flap procedure, gingivectomyon lingual surfaces), then themost inclusive procedure D4260is listed.

3. When the interval between rootplaning and osseous surgery isless than four weeks, the rootplaning is considered to beincluded in the fee for the surgery.


Osseous surgery (including flapentry and closure) — one tothree teeth in a quadrant.



Bone replacement graft — firstsite in quadrant.

1. Please submit periodontalcharting. Requires thesubmission of periodontalcharting which indicates 6 mmand above pockets, moderate tosevere bone loss, and verticalosseous defects.

2. Premier ’s allowances forprocedures D4263 and D4264are determined by site with amaximum of two sites perquadrant. Please see the





definition of “site” at the beginningof this periodontal section.

3. Please indicate the site bytooth number(s) and toothsurface(s) on the AttendingDentist’s Statement.


Bone replacement graft —additional site in the quadrant.

See procedure D4263.


Guided tissue regeneration —resorbable barrier, per site.

1. Please refer to the guidelinesfor procedure D4263.


Guided tissue regeneration —nonresorbable barrier, per site(includes membrane removal).

1. Please refer to the guidelinesfor procedure D4263.

PROCEDURE D4268 - P

Surgical revision procedure, pertooth.

1. Please submit periodontalcharting.

2. When procedure D4268follows periodontal surgery in thesame area within three years, noadditional allowance will usuallybe made.

PROCEDURE D4270 - P

Pedicle soft tissue graftprocedure.

1. Please submit completeperiodontal charting. Reportingof procedure D4270 requires thesubmission of a completeperiodontal charting showingrecession. Photographs arehelpful.

2. To be considered, recessionmust be at least 3mm withmucogingival defects.

3. Premier’s allowance is madeon a per site basis. Limited to twosites per quadrant. Please seethe definition of “site” at thebeginning of this periodontalsection.

4. Use of procedure code D4270is appropriate only when theprocedure is not performed inconjunction with any otherperiodontal services on the sametooth. When other periodontalservices are involved, this serviceis considered to be part of, andincluded in the fee for, the mostinclusive service.

5. Procedure D4270 is not abenefit when performed forcosmetic purposes.


PROCEDURE D4271 - P

Free soft tissue graft procedure(including donor site surgery).

1. Please submit completeperiodontal charting.

2. Use of procedure code D4271is appropriate only when theprocedure is not performed inconjunction with any otherperiodontal services on the sametooth. When other periodontalservices are involved, this serviceis considered to be part of, andincluded in the fee for, the mostinclusive service.

3. Please enter the tooth numberon the Attending Dentist’sStatement and circle thetreatment site(s) on the toothchart. Also, please providecomplete periodontal chartingshowing the areas of gingivalrecession (must be at least 3 mm)and any mucogingival defects.Photographs are helpful.Premier’s allowance is made ona per site basis. Limited to twosites per quadrant. Please seethe definition of “site” at thebeginning of this periodontalsection.

4. Procedure D4271 is not abenefit when performed forcosmetic purposes. The fee isthe responsibility of the patient.


6. Benefits are available onlywhen billed for natural teeth.

PROCEDURE D4273 - P

Subepithelial connective tissuegraft procedures, per tooth.

PERIODONTIC PROCEDURES (D4000 - D4999) 20 REVISED 05/09




1. Please refer to guidlines forprocedure D4271.

PROCEDURE D4274 - P

Distal or proximal wedgeprocedure (when not performedin conjunction with surgicalprocedures in the sameanatomical area).

1. Please submit periodontalcharting.

2. Requires complete periodontalcharting which indicate pockets inthe range of 6 mm and moderateto severe bone loss.

3. When this procedure isprovided in conjunction withanother periodontal surgicalprocedure, Premier’s allowancewill be based on the fee for themore inclusive procedure.

4. When D4274 is reported asprovided not in conjunction withanother periodontal procedure,the Premier consultant staff mayallow a fee equivalent toprocedures D4210, D4211,D4240, D4241, D4260, D4261, orD4342.

PROCEDURE D4275 - P

Soft tissue allograft.

1. Procedure D4275 is not abenefit of most Premierprograms. When it is provided,Premier will make an allowancebased on procedure D4273, andthe patient will be responsible forany difference in fee. Please referto the guidelines for procedureD4273.

2. Please indicate the toothnumber(s) and tooth surface(s)

on the Attending Dentist’sStatement.

PROCEDURE D4276 - P

Combined connective tissue anddouble pedicle graft, per tooth.

1. Procedure D4276 is not abenefit of Premier programs.When it is provided, Premier willmake an allowance based onprocedure D4273, and the patientwill be responsible for anydifference in fee. Please refer tothe guidelines for procedureD4273.

ADJUNCTIVEPERIODONTAL SERVICES


Periodontal scaling and rootplaning – four or more teeth perquadrant.

1. Please submit completeperiodontal charting. Requiresthe submission of clearlydiagnostic radiographs andcomplete periodontal chartingwhich indicate at least 5mm ormore pockets, and early boneloss.

2. Periodontal root planing isdefined as a definitive non-surgical periodontal treatmentinvolving the judicious andthorough planing of the rootsurface.

3. This service is not prophylaxisand scaling – see procedureD1110.

4. Please indicate the quadrant.Use the tooth chart on theAttending Dentist’s Statement toindicate missing teeth, circling thesurgical area(s). Use one line ofthe treatment form for eachquadrant, and enter a separatefee for each quadrant.

5. Periodontal root planing is gen-erally not appropriate on thesame date as procedures D1110and D4355, gingival flap proce-dure (D4240 and D4241), os-seous surgery (D4260 andD4261), gingivectomy (D4210and D4211), or periodontal main-tenance procedures (D4910).

6. Root planing is covered onceevery 24 months per quadrant.For any necessary follow-up rootplaning, see procedure D4910.

7. Periodontal root planing wouldgenerally not be used until after36 months following activeperiodontal surgery in the sameareas. See procedure D4910.

8. This service may precedesurgical services D4210, D4211,D4260, D4261, D4266 andD4267 after sufficient time (noless than four weeks) has elapsedto evaluate the tissue response.By definition, this non-surgicalprocedure would not precede orfollow gingival flap procedures(D4240 and D4241).

9. Postoperative visits andtreatment for the three monthsfollowing root planing and allsurgical periodontal services areconsidered part of, and includedin the fee for, the root planing orsurgical procedure.






Periodontal scaling and rootplanning —one to three teeth,per quadrant.


PROCEDURE D4355

Full mouth debridement toenable comprehensiveevaluation and diagnosis.

1. The fee will be paid based onprocedure D4910 fee allowance.

OTHER PERIODONTALSERVICES

PROCEDURE D4910

Periodontal maintenance.

1. Periodontal maintenanceprocedures following activetherapy. Procedure D4910 mustbe preceded by periodontalsurgery or root planing D4211,D4240, D4241, D4260, D4261,D4341, D4342.

2. Please provide the dates,areas treated and the type ofprevious periodontal treatmentperformed on the AttendingDentist’s Statement.

3. Periodontal maintenanceprocedures may be used in thosecases in which a patient hascompleted active periodontaltherapy, and commencing nosooner than three monthsthereafter. The procedureincludes any examination forevaluation, root planing and/orpolishing as may be necessary.

4. Postoperative visits andtreatment for the three monthsfollowing root planing and allsurgical periodontal services areconsidered part of, and includedin the fee for, the root planing orsurgical procedure.

5. After the initial three-monthpostoperative period, periodontalmaintenance procedures, aloneor in combination with otherprophylaxis, full mouthdebridement and/or fluorideprocedures, are subject to thesame contractual limitations aswith prophylaxis treatments,generally 1 in a 6 month period.Additional treatments are theresponsibility of the patient.

6 . Prophylaxis and fluoridetreatment are included.

PROCEDURE D4920

Unscheduled dressing change(by someone other than treatingdentist).

1. Unscheduled dressingchanges by the same dentist, orby a dentist at the same location,are considered part of, andincluded in the fees for,periodontal surgery.

2. When performed by a differentdentist at some other location,please provide a brief narrativereport citing the circumstances.

PROCEDURE D4999

Unspecified periodontal proce-dure, by report.

1. Please enter a completedescription of services andclinical reason on the AttendingDentist’s Statement.

PROSTHODONTIC PROCEDURES (D5000 - D5899) 22 REVISED 05/09




PROSTHODONTIC PROCEDURES (D5000 – D5899)

GuidelinesREMOVABLEPROSTHODONTICS –GENERAL GUIDELINES1. Premier programs do notprovide benefits for replacementof satisfactory prosthodonticappliances.

2. Under most Premier programs,prosthetic appliances are a benefitonce in a five-year period.

3. Maxillofacial prosthodontics orany appliances to correctcongenital or developmentalanomalies are not benefits of anyPremier program.

4. If the total fees for adjustments,rebase, repair and/or relineprocedures on a complete orpartial denture in the samesequence of treatment equal orexceed the fee for a complete orpartial denture, Premier ’sallowance will be based on the feefor a new appliance, and besubject to the contractuallimitations for the provision ofdentures (usually once in fiveyears). Any amount in excess tothe approved allowance is notchargeable to the patient.

5. Premier considers impressionsto be an integral part of the fee forthe final appliance.

6. Premier considers dentureadjustments provided within 12months of the placing of a dentureare considered to be included inthe fee for the denture.

7. Precision attachments; overdentures; precious metals; andfixed appliances if removable andfixed appliance are placed at thesame time in the same arch areconsidered optional treatment.The fee is the patient’sresponsibility.

8. Premier considers any rebaseto include a reline. Dentureadjustments provided within 12months of the placing of a dentureare considered to be included inthe fee for the denture.

9. A duplicate denture (a spare orsecond denture) is not a benefitunder Premier programs. The feeis the patient’s responsibility.

10. Relines should not besubmitted on a prior-authorizationrequest at the same time as thedenture. Please submit aseparate request when you areready to reline the denture.

COMPLETE DENTURES(INCLUDING ROUTINEPOST DELIVERY CARE)

PROCEDURE D5110

Complete denture, upper.

1. A standard denture is definedas a removable prostheticappliance provided to replacemissing natural, permanent teeththat is constructed using acceptedand conventional procedures andmaterials.

PROCEDURE D5120

Complete denture, lower.

1. A standard denture is definedas a removable prostheticappliance provided to replacemissing natural, permanent teeththat is constructed using acceptedand conventional procedures andmaterials.

PROCEDURE D5130

Immediate denture, upper.

1. Premier considers an upperimmediate denture to beequivalent to procedure D5110,full upper denture. Please see theguidelines for procedure D5110.

PROCEDURE D5140

Immediate denture, lower.

1. Premier considers a lowerimmediate denture to beequivalent to procedure D5120,full lower denture. Please see theguidelines for procedure D5120.

REVISED 05/09 23 PROSTHODONTIC PROCEDURES (D5000 - D5899)




PARTIAL DENTURES(INCLUDING ROUTINEPOST DELIVERY CARE)

PROCEDURE D5211

Upper partial denture – resinbase (including any conventionalclaps, rests and teeth).

1. On one line of the AttendingDentist’s Statement, pleaseindicate one fee for the entireupper partial denture. Thisprocedure is considered to includethe base and all conventionalclasps, rests and teeth.

2. Please indicate on the toothchart of the Attending Dentist’sStatement the missing teeth beingreplaced by the partial denture.

3. Removable partial dentures arenot a benefit for patients under age16. Premier may make anallowance for a space maintaineror a stayplate for anterior teeth,and the patient is responsible forthe additional fee.

PROCEDURE D5212

Lower partial denture – resinbase (including any conventionalclasps, rests and teeth).

1. On one line of the AttendingDentist’s Statement, pleaseindicate one fee for the entirelower partial denture. Thisprocedure is considered to includethe base and all conventionalclasps, rests and teeth.


3. Removable partial denturesare not a benefit for patients underage 16. Premier may make anallowance for a space maintaineror a stayplate for anterior teeth,and the patient is responsible forthe additional fee.

PROCEDURE D5213

Maxillary partial denture – castmetal framework with resindenture bases (including anyconventional clasps, rests andteeth).

1. On one line of the AttendingDentist’s Statement, pleaseindicate one fee for the entireupper partial denture. Thisprocedure is considered to includethe base and all conventionalclasps, rests and teeth.



PROCEDURE D5214

Mandibular partial denture – castmetal framework with resindenture bases (including anyconventional clasps, rests andteeth).

1. On one line of the AttendingDentist’s Statement, pleaseindicate one fee for the entirelower partial denture. Thisprocedure is considered to include

the base and all conventionalclasps, rests and teeth.



PROCEDURE D5225

Maxillary partial denture –flexible base (including anyclasps, rests and teeth).

1. On one line of the AttendingDentist’s Statement, pleaseindicate one fee for the entireupper partial denture. Thisprocedure is considered toinclude the base and allconventional clasps, rests andteeth.


3. Removable partial denturesare not a benefit for patientsunder age 16. Premier may makean allowance for a spacemaintainer or a stayplate foranterior teeth, and the patient isresponsible for the additional fee.





ADJUSTMENTS TODENTURES

PROCEDURE D5410

Adjust complete denture – upper.

1. Please refer to #6 under theGeneral Guidelines.

PROCEDURE D5411

Adjust complete denture – lower.


PROCEDURE D5421

Adjust partial denture – upper.


PROCEDURE D5422

Adjust partial denture – lower.


REPAIRS TO COMPLETEDENTURES

PROCEDURE D5510

Repair broken complete denturebase.

1. Please indicate the arch in thecolumn marked “tooth number”with an abbreviation (U = upper,L = lower).

2. Repair of broken completedenture provided within 12 monthsof the placing of a denture isconsidered to be included in thefee for the denture.

PROCEDURE D5520

Replace missing or broken teeth– complete denture (each tooth).

1. Please provide in the descrip-tion of service the total number ofteeth involved. Indicate the archin the column marked “tooth num-ber” with an abbreviation(U = upper, L = lower).

2. Replacement of missing orbroken teeth provided within 12months of the placing of a dentureis considered to be included in thefee for the denture.

REPAIRS TO PARTIALDENTURES

PROCEDURE D5610

Repair resin denture base.


2. Repair of resin denture baseprovided within 12 months of theplacing of a denture is consideredto be included in the fee for thedenture.

PROCEDURE D5226

Mandibular partial denture –flexible base (including anyclasps, rests and teeth).

1. On one line of the AttendingDentist’s Statement, pleaseindicate one fee for the fullappliance. This procedure isconsidered to include the baseand all conventional clasps, restsand teeth.


3. Removable partial denturesare not a benefit for patientsunder age 16. Premier may makean allowance for a spacemaintainer or a stayplate foranterior teeth, and the patient isresponsible for the additional fee.

PROCEDURE D5281

Removable unilateral partialdenture – one piece cast metal(including clasps and teeth).

1. On one line of the AttendingDentist’s Statement, pleaseindicate one fee for the fullappliance. This procedure isconsidered to include the baseand all conventional clasps, restsand teeth.

2. Specialized techniques,precious metal or precisionattachments are consideredoptional, and fees for such are thepatient’s responsibility. ThePremier allowance will be basedon a standard appliance.

REVISED 05/09 25 PROSTHODONTIC PROCEDURES (D5000 - D5899)




PROCEDURE D5620

Repair cast framework, byreport.

1. Please provide a full report ofthe extent of the repair on theAttending Dentist’s Statement, orattach a report if additional spaceis needed.

2. Repair of cast frameworkprovided within 12 months of theplacing of a denture is consideredto be included in the fee for thedenture.

PROCEDURE 05630

Repair or replace broken clasp.


2. Enter the fee for repair orreplacement of the clasp. If morethan one clasp is replaced orrepaired, use a separate line of theAttending Dentist’s Statement todescribe the additional repairs.

3. Repair or replacement ofbroken clasp provided within 12months of the placing of a dentureis considered to be included in thefee for the denture.

PROCEDURE D5640

Replace broken teeth – pertooth.

1. Please indicate the arch(U = upper, L = lower) in the “toothnumber” column of the AttendingDentist’s Statement.

2. Enter the fee for replacementof the first tooth. If more than onetooth is replaced, please use aseparate line of the AttendingDentist’s Statement for each tooth.

3. Replacement of broken teethprovided within 12 months of theplacing of a denture is consideredto be included in the fee for thedenture.

PROCEDURE D5650

Add tooth to existing partialdenture.


2. Enter the fee for the tooth. Ifmore than one tooth is added,please use a separate line of theAttending Dentist’s Statement foreach tooth.

PROCEDURE D5660

Add clasp to existing partialdenture.


2. Enter the fee for the clasp. Ifmore than one clasp is added,please use a separate line of theAttending Dentist’s Statement foreach clasp.

DENTURE REBASEPROCEDURES

PROCEDURE D5710

Rebase complete upper denture.

PROCEDURE D5711

Rebase complete lower denture.

PROCEDURE D5720

Rebase upper partial denture.

PROCEDURE D5721

Rebase lower partial denture.

DENTURE RELINEPROCEDURES

PROCEDURE D5730

Reline complete upper denture(chairside).

PROCEDURE D5731

Reline complete lower denture(chairside).

PROCEDURE D5740

Reline upper partial denture(chairside).





PROCEDURE D5741

Reline lower partial denture(chairside).

PROCEDURE D5750

Reline complete upper denture(laboratory).

PROCEDURE D5751

Reline complete lower denture(laboratory).

PROCEDURE D5760

Reline upper partial denture(laboratory).

PROCEDURE D5761

Reline lower partial denture(laboratory).

INTERIM PROSTHESIS

PROCEDURE D5820

Temporary partial – stayplatedenture (upper).

1. A stayplate or othertemporization service is a benefitonly to replace extractedpermanent anterior teeth for adultsduring the healing period, and asan anterior space maintainer forchildren. Any other stayplates ortemporization services areconsidered optional and are thefinancial responsibility of thepatient.

2. On one line of the AttendingDentist’s Statement, please enterone fee for the completeappliance. Procedure D5820includes all teeth and clasps.

3. Replacement of a stayplate orother temporization services is nota benefit.

PROCEDURE D5821

Temporary partial – stayplatedenture (lower).

1. A stayplate or othertemporization service is a benefitonly to replace extractedpermanent anterior tooth for adultsduring the healing period, and asan anterior space maintainer forchildren. Any other stayplates ortemporization services areconsidered optional and are thefinancial responsibility of thepatient.

2. On one line of the AttendingDentist’s Statement, please enterone fee for the completeappliance. Procedure D5821includes all teeth and clasps.

3. Replacement of a stayplate orother temporization services is nota benefit.

OTHER REMOVABLEPROSTHETIC SERVICES

PROCEDURE D5850

Tissue conditioning, maxillary.

1. A maximum of one tissueconditioning may be allowed perarch in a 12 month period. Thepatient is responsible foradditional treatments.

PROCEDURE D5851

Tissue conditioning, mandibular.

1. A maximum of one tissueconditioning may be allowed perarch in a 12 month period. Thepatient is responsible foradditional treatments.

REVISED 05/09 27 MAXILLOFACIAL PROSTHETIC PROCEDURES (D5911 - D5915)




GuidelinesMAXILLOFACIALPROSTHETICSMaxillofacial prosthetic proce-dures are not benefits of Premierprograms, and are the financialresponsibility of the patient.

MAXILLOFACIAL PROSTHETIC PROCEDURES (D5900 – D5999)

IMPLANT SERVICE PROCEDURES (D6000 - D6199) 28 REVISED 05/09




GuidelinesIMPLANT – GENERALGUIDELINES1. Implants, and procedures andappliances associated with them,are not benefits of most Premierprograms. Except when a programspecifically includes implantcoverage, Premier may make anallowance toward the cost of theappliance actually placed on theimplant (crown, bridge, partial orcomplete denture). If such anallowance is made, payment willnot be made for any replacementuntil five years have elapsed.

2. Please indicate the toothnumber into which the implantprocedure will be performed.

3. When covered by the groupcontract, replacement of an im-plant is a benefit only after fiveyears have elapsed following anyprior provision.

4. Premier considers intramucosalinserts, hydroxyapatite and simi-lar materials as implants to be nota benefit.

IMPLANT SERVICE PROCEDURES (D6000 – D6199)

REVISED 05/09 29 PROSTHODONTICS, FIXED PROCEDURES (D6200 - D6999)




GuidelinesFIXED PROSTHODONTICS– GENERAL GUIDELINES1. Prior-authorization is required.

2. Under most Premier programs,prosthetic appliances are abenefit once in a five-year period.

3. Resin-bonded bridges onprimary teeth are not a benefit ofPremier programs. Other fixedbridges and removable castpartials are not a benefit forpatients under age 16. Whenprovided, Premier may make anallowance for a space maintainer.

4. Bridges which use laminates/partial crowns, inlays and onlaysas abutments are not benefits.The fee is the patient’sresponsibility.

5. Premier programs generally donot provided benefits forreplacement of satisfactoryprosthodontic appliances.

6. Services considered integral orpart of the final restoration fee:impressions; crown build-up;tooth preparation; anesthesia;occlucal adjustment; andtemporaries/provisionals.

7. Precision attachments; fixedappliances if removable andfixed; and appliances that areplaced at the same time in thesame arch are consideredoptional treatment. The fee is thepatient’s responsibility.

8. The replacement of teethextracted before the patientbecame eligible under a Premierprogram is not generally covered.

PROSTHODONTICS, FIXED (D6200 – D6999)

9. Treatment correcting congeni-tal or developmental malforma-tions are not benefits.

10. Replacement of congenitallymissing permanent teeth is not abenefit, regardless of the lengthof time the deciduous tooth isretained.

11. In the date service performedcolumn of Attending Dentist’sStatement, indicate the date theprosthetic appliance was perma-nently cemented. Impressiondates should not be indicatedunless specifically requested byPremier.

12. Under most Premierprograms cantilever bridges onposterior teeth are not a benefit.The fee is the patient’s responsi-bility.

13. A bridge replacing extractedroot when the majority of thenatural crown is missing is not acovered benefit.

FIXED PARTIAL DENTUREPONTICS

PROCEDURE D6210 - X

Pontic – cast high noble metal.

1. Please use a separate line ofthe Attending Dentist’s Statementfor each tooth involved in the fixedbridge. Indicate a separate feefor each tooth.

PROCEDURE D6211 - X

Pontic – cast predominately basemetal.

1. Please refer to procedureD6210.

PROCEDURE D6212 - X

Pontic – cast noble metal.

1. Please refer to procedure#D6210.

PROCEDURE D6214 - X

Pontic – titanium.


PROCEDURE D6240 - X

Pontic – porcelain fused to highnoble metal.


PROCEDURE D6241 - X

Pontic – porcelain fused topredominately base metal.


PROCEDURE D6242 - X

Pontic – porcelain fused to noblemetal.


PROSTHODONTICS, FIXED PROCEDURES (D6200 - D6999) 30 REVISED 05/09




2. Premier considers interimpontic to be part of and includedin the fee for the completedprosthodontic appliance.

FIXED PARTIAL DENTURERETAINERS - INLAYS/ONLAYS

PROCEDURE D6600

Inlay – porcelain/ceramic, twosurfaces.

1. Please refer to the GeneralGuidelines.

PROCEDURE D6601

Inlay – porcelain/ceramic, threeor more surfaces.


PROCEDURE D6602

Inlay – cast high noble metal,two surfaces.


PROCEDURE D6603

Inlay – cast high noble metal,three or more surfaces.


PROCEDURE D6250 - X

Pontic – resin with high noblemetal.


PROCEDURE D6251 - X

Pontic – resin with predominantlybase metal.


PROCEDURE D6252 - X

Pontic – resin with noble metal.


PROCEDURE D6253 - X

Provisional pontic.

1. Premier considers provisionalpontics to be part of and includedin the fee for the completedprosthodontic appliance.

PROCEDURE D6254 - X

Interim pontic.

1. Pontic used as in interimrestoration for a duration of lessthan six months when a finalimpression is not made to allowadequate time for healing orcompletion of definitive treatmentplanning. This is not a temporarypontic for routine prosthetic fixedpartial denture restoration.

PROCEDURE D6604

Inlay – cast predominantly basemetal, two surfaces.


PROCEDURE D6605

Inlay – cast predominantly basemetal, three or more surfaces.


PROCEDURE D6606 - X

Inlay -— cast noble metal, twosurfaces.


PROCEDURE D6607 - X

Inlay -— cast noble metal, threeor more surfaces.


FIXED PARTIAL DENTURERETAINERS – CROWNS

PROCEDURE D6720 - X

Crown — resin with high noblemetal.

1. This code is the prostheticequivalent of procedure D2720.Please use procedure D2720 ifthe crown is not a part of aprosthetic appliance.





PROCEDURE D6721 - X

Crown — resin withpredominantly base metal.


PROCEDURE D6722 - X

Crown — resin with noble metal.


PROCEDURE D6750 - X

Crown – porcelain fused to highnoble metal.

1. Please enter the tooth numberon the Attending Dentist’sStatement. Use a separate linefor each tooth involved in the fixedbridge and indicate a separate feefor each unit.


PROCEDURE D6751 - X

Crown – porcelain fused topredominately base metal.

1. Please enter the tooth numberon the Attending Dentist’sStatement. Use a separate line

for each tooth involved in the fixedbridge and indicate a separate feefor each unit.

2. This code is the prostheticequivalent of procedure D2751.Please use procedure D2751 ifthe crown is not part of a prostheticappliance.

PROCEDURE D6752 - X

Crown – porcelain fused tonoble metal.



PROCEDURE D6780 - X

Crown – ¾ cast high noblemetal.



PROCEDURE D6781 - X

Crown — 3/4 cast predominantlybase metal.


2. This code is the prostheticequivalent of procedure D2781.Please use procedure D2781 ifthe crown is not part of aprosthetic appliance.

PROCEDURE D6782 - X

Crown — 3/4 cast noble metal.



PROCEDURE D6783 - X

Crown — 3/4 porcelain/ceramic.



PROSTHODONTICS, FIXED PROCEDURES (D6200 - D6999) 32 REVISED 05/09




PROCEDURE D6790 - X

Crown – full cast high noblemetal.



PROCEDURE D6791 - X

Crown – full cast predominatelybase metal.



PROCEDURE D6792 - X

Crown – full cast noble metal.



PROCEDURE D6793 - X

Provisional retainer crown.

1. Under most Premier programs,this procedure is not a coveredbenefit. The fee is the patient’sresponsibility.

PROCEDURE D6794

Crown — titanium.

1. Under most Premier programsthis procedure is not a coveredbenefit. Premier will make anallowance based on theequivalent base metal procedure.

OTHER FIXED PARTIALDENTAL SERVICES

PROCEDURE D6930

Recement bridge.

1. Premier considers fees forrecementation to be included inthe cost of covered restorationsfor 12 months following initialplacement. During this period, aseparate fee for recementation isnot chargeable.

2. Please enter in the descriptionof service the tooth number ofeach tooth included in the bridge.

PROCEDURE D6970

Cast post and core in addition tobridge retainer.

1. Premier considers thisprocedure a covered benefit onlyfor endodontically treated teethrequiring crowns.

2. Premier allows for one post andcore per tooth. A separate fee isnot chargeable to the patient.

3. This code is the prostheticequivalent of procedure D2952.Please use procedure D2952 ifthe post and core are not part ofa prosthetic appliance.

4. When the post is prefabricatedas part of the bridge, useprocedure D6972.

5. This procedure applies to anindividually fitted and custom castpost (including a core and coping)that is necessary for placementinto the endodontically treatedcanal when the remaining toothstructure is insufficient for bridgeplacement. This procedure isconsidered to include the postand any core buildup. Pleaseenter the tooth number anddescribe the service fully on theAttending Dentist’s Statement.

PROCEDURE D6972

Prefabricated post and core inaddition to bridge retainer.

1. Premier considers thisprocedure a covered benefit onlyfor endodontically treated teethrequiring crowns.





2. Premier allows for one post andcore per tooth. A separate fee isnot chargeable to the patient.

3. This code is the prostheticequivalent of procedure D2954.Please use procedure D2954 ifthe post and core are not part ofa prosthetic appliance. Thisprocedure is considered toinclude the post and any corebuildup/substructure.

4. Please enter the tooth numberon the Attending Dentist’sStatement.

PROCEDURE D6973

Core build up for retainer,including any pins.

1. This procedure is not a benefitof most Premier programs.

PROCEDURE D6980

Bridge repair, by report.

1. Please write a report on theAttending Dentist’s Statement onthe duration of treatment or repair.If additional space is needed,attach a report to the treatmentform. The allowance will bedetermined after evaluation bythe Premier consultant staff,based on time and laboratorycharges.

ORAL AND MAXILLOFACIAL SURGERY (D7000 - D7999) 34 REVISED 05/09




GuidelinesORAL SURGERY –GENERAL GUIDELINES1. Removal of pathology free 3rdmolars is not a benefit of mostPremier programs.

2. Removal of pathology freeprimary teeth that are not nearexfoliation is not a benefit of mostPremier programs.

3. Any hospital or hospital relatedfees associated with an oralsurgery procedure are notcovered benefits and are thefinancial responsibility of thepatient.

4. Fees for oral surgeryprocedures include localanesthesia and routinepostoperative visits. For generalanesthesia, see proceduresD9220 and D9221. For I.V.sedation, see procedure D9241.

EXTRACTIONS

PROCEDURE D7111

Extraction, coronal remnants –deciduous tooth.

PROCEDURE D7140

Extraction, erupted tooth orexposed root (elevation and/orforceps removal).

ORAL AND MAXILLOFACIAL SURGERY (D7000 - D7999)

SURGICAL EXTRACTIONS

PROCEDURE D7210 - X

Surgical removal of eruptedtooth.

1. This service is defined as thereflection of a soft tissue flap andthe removal of bone and/or thesectioning of the tooth.

2. When multiple surgicalextractions are provided, they areconsidered to include anynecessary alveoloplasty.

PROCEDURE D7220 - X

Removal of impacted tooth –soft tissue.

1. Premier bases the classificationof impactions on the anatomicalposition of the tooth rather thanthe surgical technique employedin the removal of the tooth.

2. The procedure is considered toinclude the excision of associatedminor cystic or inflamed softtissue.

PROCEDURE D7230 - X

Removal of impacted tooth –partially bony.


PROCEDURE D7240 - X

Removal of impacted tooth –completely bony.


PROCEDURE D7241 - X

Removal of impacted tooth –completely bony, with unusualsurgical complications.

1. Please submit a narrative.


PROCEDURE D7250 - X

Surgical removal of residualtooth roots (cutting procedure).

PROCEDURE D7251 - X

Coronectomy: Intentional partialtooth removal

1. This procedure includesmucoperiosteal flap elevation,bone removal, tooth sectioning,and removal of tooth structure,minor smoothing of socket boneand closure.

2. Premier bases theclassification of impactions on theanatomical position of the toothrather than the surgical techniqueemployed in the removal of thetooth.

REVISED 05/09 35 ORAL AND MAXILLOFACIAL SURGERY (D7000 - D7999)




3. Intentional partial toothremoval is applicable when aneurovascular complication islikely if the entire impacted toothis removed.

4. Requires submission ofdiagnostic radiographs

5. Subjects to exclusions forsupernumerary tooth

OTHER SURGICALPROCEDURES

PROCEDURE D7260 - X

Oral antral fistula closure.

1. Please submit a brief history,and a surgical report.

PROCEDURE D7261 - X

Primary closure of a sinusperforation.

1. Please submit a brief history,and a surgical report.

PROCEDURE D7270 - X

Tooth reimplantation andstabilization of accidentallyevulsed or displaced tooth and/or alveolus.

1. Please submit an operativereport.

2. This procedure is coveredunder most Premier programs andis limited to permanent teeth only.

PROCEDURE D7272 - X

Tooth transplantation (includesreimplantation from one site toanother and splinting and/orstabilization).

1. This procedure is not a benefitof most Premier programs. Thefee is the patient’s responsibility.

PROCEDURE D7280 - X

Surgical access of an uneruptedtooth.

1. Please use one line of theAttending Dentist’s Statement foreach tooth involved. Indicate thetooth number or letter and therequested fee for each tooth.

PROCEDURE D7285

Biopsy of oral tissue – hard.

1. Please attach a copy of thepathology report.

2. This procedure includes the feefor the resection of hard tissue.

PROCEDURE D7286

Biopsy of oral tissue - soft.

1. Please attach a copy of thepathology report.

2. This procedure includes the feefor the resection of tumors andexcision of cysts.

ALVEOLOPLASTY

PROCEDURE D7310

Alveoloplasty in conjunction withextractions – four or more teethor tooth spaces, per quadrant.

1. Procedures D7310 and D7311cannot be charged separatelywhen procedures D7210 throughD7250 are performed.

2. Frenectomy cannot be chargedseparately when D7310, D7311,D7320, and D7321 are performed.

3. Please use a separate line foreach quadrant involved. Indicatethe quadrant by abbreviation (UR,UL, LR, LL) in the area for oralcavity.

PROCEDURE D7311

Alveoloplasty in conjunction withextractions – one to three teethor tooth spaces, per quadrant.


2. A bounded tooth space iscounted as one space regardlessof the number of teeth that wouldnormally exist in the space.

PROCEDURE D7320

Alveoloplasty not in conjunctionwith extractions – four or moreteeth or tooth spaces, perquadrant.





the vestibuloplasty are not ben-efits of Premier programs. Suchan additional fee should be indi-cated on the Attending Dentist’sStatement as a separate item.The fee is the patient’s responsi-bility.

3. Frenectomy cannot becharged separately.

REMOVAL OF TUMORS,CYSTS AND NEOPLASMS

PROCEDURE D7410

Excision of benign lesion up to1.25 cm.

1. Please submit operative andpathology reports. The allowancewill be determined by Premier’sconsultant staff.

PROCEDURE D7411

Excision of benign lesiongreater than 1.25 cm.

1. Please submit operative andpathology reports.

PROCEDURE D7412

Excision of benign lesion,complicated.

1. Please identify area of thelesion and provide the operativeand pathology reports. Theallowance will be determined byPremier’s consultant staff.

PROCEDURE D7413

Excision of malignant lesion upto 1.25 cm.

1. Please identify area of the lesionand provide operative andpathology reports. The allowancewill be determined by Premier’sconsultant staff.

PROCEDURE D7414

Excision of malignant lesiongreater than 1.25 cm.

1. Please identify area of the lesionand provide operative andpathology reports. The allowancewill be determined by Premier’sconsultant staff.

PROCEDURE D7415

Excision of malignant lesion,complicated.

1. Please identify area of thelesion and provide operative andpathology reports. The allowancewill be determined by Premier’sconsultant staff.

PROCEDURE D7440

Excision of malignant tumor –lesion diameter up to 1.25 cm.

1. Please identify area of tumorand provide operative andpathology report. The allowancewill be determined by Premier’sconsultant staff.

1. Please use a separate line foreach quadrant involved. Indicatethe quadrant by abbreviation (UR,UL, LR, LL) in the area for oralcavity.

PROCEDURE D7321

Alveoloplasty not in conjunctionwith extractions –one to threeteeth or tooth spaces, perquadrant.


2. A bounded tooth space iscounted as one space regardlessof the number of teeth that wouldnormally exist in the space.

VESTIBULOPLASTYSurgical procedures designed toincrease alveolar ridge height.

PROCEDURE D7340

Vestibuloplasty – ridge extension(secondary epithelialization).

1. Please provide an operativereport for review by the Premierconsultant staff.

PROCEDURE D7350

Vestibuloplasty – ridge extension(including soft tissue attachmentand management ofhypertrophied and hyperplastictissue).

1. Please provide an operativereport for review by the Premierconsultant staff.

2. Bone or other hard tissue orsynthetic grafts used to augment





PROCEDURE D7441

Excision of malignant tumor –lesion diameter greater than1.25 cm.

1. Please identify area of tumorand provide operative andpathology report. The allowancewill be determined by Premier’sconsultant staff.

PROCEDURE D7450 - X

Removal of odontogenic cyst ortumor – lesion diameter up to1.25 cm.

1. Indicate the location of the cystand provide a copy of thepathology report.

PROCEDURE D7451 - X

Removal of odontogenic cyst ortumor – lesion diameter greaterthan 1.25 cm.


PROCEDURE D7460 - X

Removal of nonodontogenic cystor tumor – lesion diameter up to1.25 cm.


PROCEDURE D7461 - X

Removal of nonodontogenic cystor tumor – lesion diametergreater than 1.25 cm.


PROCEDURE D7465

Destruction of lesion(s) byphysical methods, by report.

1. Please include a written reporton the Attending Dentist’sStatement. The allowance will bedetermined by Premier ’sconsultant staff.

EXCISION OF BONETISSUE

PROCEDURE D7471 - X

Removal of lateral exostosis(maxilla or mandible).

1. Please identify the quadranttreated by abbreviation (UR, UL,LR, LL) in the area for oral cavity.If multiple quadrants are involved,use separate lines for eachquadrant.

PROCEDURE D7472 - X

Removal of torus palatinus.

PROCEDURE D7473 - X

Removal of torus mandibularis.

1. Please indicate the quadrant onthe claim (LR or LL).

PROCEDURE D7485 - X

Surgical reduction of osseoustuberosity.

1. Please indicate the quadrant onthe claim (UR or UL).

PROCEDURE D7490 - X

Radical resection of mandiblewith bone graft.

1. An operative report must beprovided on the Attending Dentist’sStatement or attached when morespace is needed. Please enclose acopy of the pathology report for reviewby the Premier consultant staff todetermine the allowance.

SURGICAL INCISION

PROCEDURE D7510

Incision and drainage ofabscess – intraoral soft tissue.

1. This procedure involvesincision and the placement of asurgical draining device.

2. Please provide brief clinicaldescription on the AttendingDentist’s Statement for review bythe Premier consultant staff.

3. When services are rendered onthe same day, by the same dentistor dental office as endodontic,extractions, palliative treatment orother definitive services they areconsidered to be part of andincluded in the fee of theprocedure.





PROCEDURE D7511

Incision and drainage ofabscess – intraoral soft tissue –complicated (includes drainageof multiple fascial spaces).

1. Please submit an operativereport for review by the Premierconsultant staff to determine theallowance.

2. When services are rendered onthe same day, by the same dentistor dental office as endodontic,extractions, palliative treatment orother definitive services they areconsidered to be part of andincluded in the fee of theprocedure.

PROCEDURE D7520

Incision and drainage ofabscess – extraoral soft tissue.

1. Please provide history and anoperative report for review by thePremier consultant staff.

2. This procedure is a benefit ofPremier programs only if cause ofinfection is dental in nature.

PROCEDURE D7521

Incision and drainage ofabscess — extraoral soft tissue— complicated (includesdrainage of multiple fascialspaces).

1. Please submit an operativereport for review by the Premierconsultant staff to determine theallowance.

2. This procedure is a benefit ofPremier programs only if cause ofinfection is dental in nature.

PROCEDURE D7530

Removal of foreign body, skin orsubcutaneous alveolar tissue.

1. Please identify the nature ofthe foreign body on the AttendingDentist’s Statement.

PROCEDURE D7540 - X

Removal of foreign bodies –musculoskeletal system.

1. Please identify the nature of theforeign body on the AttendingDentist’s Statement.

2. Please submit to Medical car-rier first. Based on Premier ’sconsulting staff review, proceduremay be considered for payment.

PROCEDURE D7550 - X

Partial ostectomy/sequestrec-tomy for removal of non-vitalbone.

1. Please submit to Medical carrierfirst. Based on Premier ’sconsulting staff review, proceduremay be considered for payment.

2. This procedure is defined asthe surgical removal of loose orsloughed-off dead bone.

PROCEDURE D7560 - X

Maxillary sinusotomy for removalof tooth fragment or foreignbody.

1. Please submit a brief historyand an operative report.

2. Please submit to Medical carrierfirst. Based on Premier ’sconsulting staff review, proceduremay be considered for payment.

TREATMENT OFFRACTURES – SIMPLE

PROCEDURE D7610 - X

Maxilla – open reduction (teethimmobilized if present).


PROCEDURE D7620 - X

Maxilla – closed reduction (teethimmobilized if present).


PROCEDURE D7630 - X

Mandible – open reduction(teeth immobilized if present).


PROCEDURE D7640 - X

Mandible – closed reduction(teeth immobilized if present).


PROCEDURE D7650 - X

Malar and/or zygomatic arch –open reduction.






PROCEDURE D7660 - X

Malar and/or zygomatic arch –closed reduction.


PROCEDURE D7670 - X

Alveolus – stabilization of teeth,open reduction splinting.


PROCEDURE D7671 - X

Alveolus — open reduction, mayinclude stabilization of teeth.


PROCEDURE D7680 - X

Facial bones – complicatedreduction with fixation andmultiple surgical approaches.


TREATMENT OFFRACTURES –

COMPOUND

PROCEDURE D7710 - X

Maxilla – open reduction.


PROCEDURE D7720 - X

Maxilla – closed reduction.


PROCEDURE D7730 - X

Mandible - open reduction.


PROCEDURE D7740 - X

Mandible - closed reduction.


PROCEDURE D7750 –X

Malar and/or zygomatic arch –open reduction.


PROCEDURE D7760 - X

Malar and/or zygomatic arch –closed reduction.


PROCEDURE D7770 - X

Alveolus – stabilization of teeth,open reduction splinting.


PROCEDURE D7771 - X

Alveolus — closed reductionstabilization of teeth.


PROCEDURE D7780 - X

Facial bones – complicatedreduction with fixation andmultiple surgical approaches.


REDUCTION OFDISLOCATION ANDMANAGEMENT OF OTHERTEMPOROMANDIBULARJOINT DYSFUNCTIONS

GENERAL GUIDELINES1. Through a contract rider to thestandard group contract, a fewPremier groups provide limitedcoverage for certain TMJ services,





subject to a lifetime maximumallowance:

D7880 Occlusal orthotic device

D9940 Occlusal guard

D9952 Occlusal adjustment –complete.

2. Except for services notedabove, services related to TMJdysfunction are excluded. Repairor replacement of any appliancefurnished in whole or in part asTMJ benefits is not covered. Thefee is the patient’s responsibility.

3. Services which would normallybe provided under medical careare not a covered benefit.

PROCEDURE D7810

Open reduction of dislocation.


PROCEDURE D7820

Closed reduction of dislocation.


PROCEDURE D7830

Manipulation under anesthesia.


PROCEDURE D7840

Condylectomy.


PROCEDURE D7850

Meniscectomy.


PROCEDURE D7880

Occlusal orthotic device.

1. This procedure is not a benefitof most Premier programs.

2. Authorization is requiredwhen the group contract providescoverage for this and other TMJservices.

3. Replacement or repair of anocclusal orthotic device providedunder a Premier program is notcovered.

REPAIR OF TRAUMATICWOUNDS

PROCEDURE D7910

Suture of recent small wounds upto 5 cm.

1. A report of the extent of thetreatment must be submitted.Please provide a written report onthe Attending Dentist’s Statementor attach a report when morespace is needed. The clinicalremarks will be reviewed by

Premier ’s consultant staff todetermine the allowance.

COMPLICATED SUTURING

PROCEDURE D7911

Suture of complex wounds up to5 cm.

1. A report of the extent oftreatment must be submitted.Please provide a written report onthe Attending Dentist’s Statementor attach a report when morespace is needed. The clinicalremarks will be reviewed byPremier ’s consultant staff todetermine the allowance.

PROCEDURE D7912

Suture of complex woundsgreater than 5 cm.

1. A report of the extent oftreatment must be submitted.Please provide a written report onthe Attending Dentist’s Statementor attach a report when morespace is needed. The clinicalremarks will be reviewed byPremier ’s consultant staff todetermine the allowance.

OTHER REPAIRPROCEDURES

PROCEDURE D7960

frenulectomy – (frenectomy orfrenotomy) – separate procedurenot incidental to anotherprocedure





1. This procedure is for surgicalremoval or release of mucosaland muscle elements of a buccal,labial or lingual frenum that isassociated with a pathologicalcondition, or interferes withproper oral development ortreatment.

PROCEDURE D7963

Frenuloplasty.

1. Under Premier’s processingpolicies, frenuloplasty cannot becharged separately whenperformed with other surgicalprocedures in the same surgicalsite.

PROCEDURE D7970

Excision of hyperplastic tissue –per arch.

1. Please identify the arch treatedas either U (upper arch) or L(lower arch) in the column markedoral cavity on the AttendingDentist’s Statement. If botharches are involved, use two linesof the treatment form and enter aseparate fee for each arch.

PROCEDURE D7971-X

Excision of pericoronal gingiva.

1. Please submit a narrativereport for exceptional circum-stances.

2. Applies most commonly to theremoval of the operculum in thethird molar region.

3. The preparation of gingivaltissues for placing a crown or

other restoration is included in thefee for restoration.

PROCEDURE D7972

Surgical reduction of fibroustuberosity.

1. Please indicate the quadranton the claim (UL or UR).

2. Under Premier’s processingpolicies, procedure D7972cannot be charged separatelywhen procedures D4210, D4211,D4260 and D4261 are performedsimultaneously.

PROCEDURE D7980 - X

Sialolithotomy.

1. Please submit a narrativereport for exceptional circum-stances.

PROCEDURE D7981 - X

Excision of salivary gland, byreport.

1. Please submit a detailedoperative report.

2. The Premier consultant staff willdetermine Premier’s allowance.

PROCEDURE D7982

Sialodochoplasty.

1. Please provide an operativereport documenting the need forthe procedure for review by thePremier consulting staff.

PROCEDURE D7983

Closure of salivary fistula.

1. Please provide clinical historyof the patient’s condition and anoperative report for review byPremier’s consultant staff.

ORTHODONTIC PROCEDURES (D8000 - D8999) 42 REVISED 05/09




GuidelinesORTHODONTICS –GENERAL GUIDELINES1. To determine whether yourpatient has orthodontic benefits,please call 888-715-0760.

2. Orthognathic surgery isgenerally a benefit of groups withorthodontic coverage.

3. Services related to orthodontictreatment are usually benefits ofa patient’s diagnostic or basiccoverage, whether or not theprogram provides orthodonticcoverage. Such procedures mayinclude examination, x-rays andextractions.

4. All orthodontic services includeall appliances, adjustments, in-sertion, removal and post treat-ment stabilization.

5. Premier’s orthodontic codingand nomenclature classifies treat-ment based on two factors: thetype of dentition (primary, transi-tional/mixed, and permanent) andthe expected duration of the ac-tive phase of treatment. Whensubmitting a claim or request forprior-authorization, please selectthe code that corresponds tothe patient’s dentition and mostclosely to the estimated lengthof treatment.

6. Cases involving minortreatment for tooth guidance andinterceptive orthodontic treatmentshould be submitted under thecodes for limited treatment (codesD8010-D8020, D8030, andD8040).

7. Please do not submit x-rays ordiagnostic casts with orthodonticclaims or requests for prior-authorization unless specificallyrequested to do so by Premier.

8. Benefits for orthodontictreatment are payable only if thetreatment starts after a CoveredPerson’s effective date ofcoverage. If orthodontic treatmentis started prior to a CoveredPerson’s effective date ofcoverage under this Policy, thetotal orthodontic benefit amountpaid prior to the effective date isrequired for payment and will bededucted from the LifetimeMaximum Benefit under thisRider.

9. Benefits are payable only whenbilled separately for initial bandingand monthly or quarterlymaintenance.

10. Repairs or replacement of anyappliance inserted under Premieris not a covered benefit. The feeis the patient’s responsibility.

LIMITED ORTHODONTICTREATMENT

PROCEDURE D8010

Limited orthodontic treatment ofthe primary dentition.

PROCEDURE D8020

Limited orthodontic treatment ofthe transitional dentition.

PROCEDURE D8030

Limited orthodontic treatment ofthe adolescent dentition.

PROCEDURE D8040

Limited orthodontic treatment ofthe adult dentition.

INTERCEPTIVEORTHODONTICTREATMENT

PROCEDURE D8050

Interceptive orthodontic treatmentof the primary dentition.

PROCEDURE D8060

Interceptive orthodontic treatmentof the transitional dentition.

ORTHODONTICS (D8000 – D8999)

REVISED 05/09 43 ORTHODONTIC PROCEDURES (D8000 - D8999)




COMPREHENSIVEORTHODONTIC

PROCEDURE D8070

Comprehensive orthodontictreatment of the transitionaldentition.

PROCEDURE D8080

Comprehensive orthodontictreatment of the adolescentdentition.

PROCEDURE D8090

Comprehensive orthodontictreatment of the adult dentition.

MINOR TREATMENT TOCONTROL HARMFULHABITS

PROCEDURE D8210

Appliance to control harmfulhabits (removable).

PROCEDURE D8220

Appliances to control harmfulhabits (fixed or cemented).

OTHER ORTHODONTICSERVICES

PROCEDURE D8660

Pre-orthodontic treatment visit.

1. Under Premier’s processingpolicies, this procedure isequivalent to procedure D0150,and is a benefit only for patientswith orthodontic coverage.

PROCEDURE D8670

Periodic orthodontic treatmentvisit (as part of contract).

1. Premier considers periodictreatment visits to be included inthe fee for any definitive activeorthodontic treatment.

PROCEDURE D8680

Orthodontic retention (removal ofappliances, construction andplacement of retainer[s]).

1. Under Premier’s processingpolicies, the removal oforthodontic appliances is includedin the fees for orthodontictreatment when performed by thesame dentist or dental office.

PROCEDURE D8690

Orthodontic treatment (alternativebilling to a contract fee).

1. Please submit documentation.The orthodontic and consultantstaff will determine Premier ’sallowance.

PROCEDURE D8693

Rebonding or recementing; and/or repair, as required, of fixedretainers.

ADJUNCTIVE GENERAL SERVICES (D9000 - D9999) 44 REVISED 05/09




ADJUNCTIVE GENERAL SERVICES (D9000 – D9999)

GuidelinesUNCLASSIFIEDTREATMENT

PROCEDURE D9110

Palliative (emergency) treatmentof dental pain – minor procedure.

1. This service is payable per visit,not per tooth, and fee includes alltreatment provided (other thanrequired x-rays).

2. Emergencies cannot besubmitted for predetermination ofcost.

3. A temporary restoration isconsidered a component of, andincluded in the fee for, the finalrestoration. Such temporaryrestorations are not consideredemergency palliatives.

4. Please provide in thedescription of service adescription of the nature of theemergency and the treatmentprovided.

PROCEDURE D9120

Fixed partial denture sectioning.

1. Premier considers thisprocedure to be part of andincluded in the fee for the service.No separate benefit is payable.

ANESTHESIA

PROCEDURE D9210

Local anesthesia not inconjunction with operative orsurgical procedures.


PROCEDURE D9211

Regional block anesthesia.


PROCEDURE D9212

Trigeminal division blockanesthesia.


PROCEDURE D9215

Local anesthesia in conjunctionwith operative or surgicalprocedures.

PROCEDURE D9220

General anesthesia – first 30minutes.

1. General anesthesia is a benefitof most Premier programs onlywhen provided by a dentist inconjunction with covered complexoral surgery procedures. Whenotherwise provided, the patient isresponsible for the fee.

2. General anesthesia is coveredwhen administered in the dentaloffice. Additional charges foranesthesiologists and associatedservices are the patient’sresponsibility.

3. Please enter the permitnumber on or below thedescription of service.

4. If more than 30 minutes ofgeneral anesthesia isadministered, please seeprocedure D9221.

PROCEDURE D9221

General anesthesia – eachadditional 15 minutes.

1. Indicate a separate fee and aseparate line on the claim formfor each 15-minute period.

REVISED 05/09 45 ADJUNCTIVE GENERAL SERVICES (D9000 - D9999)




PROCEDURE D9241

Intravenous conscious sedation/analgesia – first 30 minutes.

1. Intravenous conscioussedation is a benefit of mostPremier programs only whenprovided by a dentist inconjunction with covered complexoral surgery procedures.

2. Allowance for I.V. sedation isfor office administration only.Additional charges foranesthesiologists and associatedservices are the patient’sresponsibility.

3. Please enter the permit numberon or below the description ofservice.

4. If more than 30 minutes of I.V.sedation is administered, pleasesee procedure D9242.

PROCEDURE D9242

Intravenous conscious sedation/analgesia – each additional 15minutes.

PROFESSIONALCONSULTATION

PROCEDURE D9310

Consultation – diagnosticservice provided by dentist orphysician other than requesting

dentist or physician.

1. This procedure includes anyexamination.

2. This procedure is covered onlywhen no other services areprovided on the same date ofservice, except x-rays.

PROFESSIONAL VISITS

PROCEDURE D9430

Office visit for observation(during regularly scheduledhours) – no other servicesperformed.

1. This is not an examinationprocedure.

2. This procedure is not payablein conjunction with hospital visits,periodontal recalls, orthodonticobservation or as a routine post-operative visit.

PROCEDURE D9440

Office visit – after regularlyscheduled hours.

1. Any additional servicesprovided should be indicated byspecific procedure codes onseparate lines of the AttendingDentist’s Statement.

DRUGS

PROCEDURE D9930

Treatment of complications(post-surgical) – unusualcircumstances, narrative reportrequired.

1. Please provide a narrativedescription of the complicationsin the description of service forreview by Premier‘s consultantstaff.

PROCEDURE D9940

Occlusal guard, by report.

1. Occlusal guards are notbenefits of most Premierprograms.

2. Some Premier groups mayinclude coverage for an occlusalguard as part of their periodontalbenefits.

3. Repair or replacement of anocclusal guard is not a benefit.

PROCEDURE D9942

Repair and/or reline of occlusalguard.


2. Repair and/or reline of occlusalguards is not usually a benefit ofthe limited number of Premierprograms that cover D9940.

3. If the patient’s program coversD9942, the consultant staff willdetermine Premier’s allowancebased on the narrative reportsubmitted with the claim.

ADJUNCTIVE GENERAL SERVICES (D9000 - D9999) 46 REVISED 05/09




PROCEDURE D9950

Occlusion analysis – mounted,including all related procedures.

1. This procedure is a benefit foronly those groups with TMJcoverage.

PROCEDURE D9951

Occlusal adjustment – limited.

1. Limited occlusal adjustment isnot a benefit of most Premierprograms.

2. This service cannot be chargedseparately when restorative orprosthodontic procedures areperformed.

3. For groups which cover thisprocedure (providing limitedcoverage for certain TMJservices), authorization isrequired.

4. Please indicate the quadranttreated by abbreviation (UR, UL,LR, LL) in the column marked“tooth number” on the AttendingDentist’s Statement. Use one lineof the treatment form for eachquadrant and enter a separate feefor each quadrant.

PROCEDURE D9952

Occlusal adjustment – complete.

1. Complete occlusal adjustmentis not a benefit of most Premierprograms.

2. For groups which cover thisprocedure (providing limitedcoverage for certain TMJservices), authorization isrequired.

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