The purpose of our Dental Policy Manual is to document the sources and principles used in writing our Dental Policies. This information is to be used as a general reference resource regarding our Dental Policies and not intended to address every aspect of a dental situation. Reasonable discretion may be used in applying our Dental Policies to individual situations.
The following national source, the American Dental Association (ADA) Code on Dental Procedures and Nomenclature (CDT), is consulted in the development of our health plan Dental Policies.
Comments from dental providers regarding dental policies are welcome. If you have a question or comment regarding a dental policy, please contact your provider relations representative.
Your use of this Dental Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Dental Policy Disclaimer.
Table of contents
- Administrative Guidelines to Determine Dental vs Medical Services -- Note effective February 1, 2014 this policy was moved to the Medical Policy in the Allied Health Section, Policy #35
- Dental Accident
- Laser Treatment for Restorative Procedures
- Multiple Surface Restorations, Same Tooth
- Non-Reimbursable Dental Services
- Temporomandibular Joint Dysfunction
- Tongue Thrust Therapy
- Apically Positioned Flap
- Autogenous Connective Tissue Graft
- Bone Replacement Graft
- Chemotherapeutic Agents
- Combined Connective Tissue and Double Pedicle Graft
- Distal or Proximal Wedge Procedure
- Free Soft Tissue Graft
- Full Mouth Debridement
- Non-autogenous Connective Tissue Graft
- Pedicle Soft Tissue Graft
- Surgical Revision Procedure, per Tooth