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Policy No:  12

Originally Created: 03/01/1997

Section: Restorative

Last Reviewed:  01/01/2019

Last Revised:  01/01/2018

Approved: 01/01/2018

Effective:  01/01/2018

Description

Preventive resin restoration in a moderate to high caries risk patient – permanent tooth (D1352)

Direct resin restorations (D2330-D2394)

Resin-based composite refers to a broad category of materials including but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases and curing, are included as part of the restoration. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, they should be reported separately (see D2951).

Procedure
Code
Description
Resin based composite D2330 one surface,anterior
Resin based composite D2331 two surfaces, anterior
Resin based composite D2332 three surfaces, anterior
Resin based composite D2335 four or more surfaces or invoving incisional angle (anterior)
Resin based composite D2390 anterior
Resin based composite D2391 one surface, posterior
Resin based composite D2392 two surfaces, posterior
Resin based composite D2393 three surfaces, posterior
Resin based composite D2394 four or more surfaces, posterior

 

Policy/criteria

Procedures are in accordance with generally accepted standards of dental practice.

Light curing, acid etching, adhesives, liners and bases are included as part of restorations.

Administrative guidelines

Process to contract benefits.

Codes

CDT - D2000-D2999 - see above

Disclaimer

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.