Dental Clinical Policies and Guidelines
The Dental Clinical Policies, Dental Coverage Guidelines and corresponding update bulletins for UnitedHealthcare Dental plans are listed below.
A monthly notice of recently approved and/or revised Dental Clinical Policies and Coverage Guidelines is provided below for your review. We publish a new announcement on the first calendar day of every month.
The appearance of a dental service (e.g., procedure or technology) in the Dental Policy Update Bulletin does not imply that UnitedHealthcare provides coverage for the dental service. In the event of an inconsistency or conflict between the information provided in the Dental Policy Update Bulletin and the posted policy, the provisions of the posted policy will prevail.
01/01/2025 – Dental Policy Update Bulletin: January 2025open_in_new
Last Published 01.01.2025
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Dental Clinical Policies, Coverage Guidelines, and Review Guidelines.
02/01/2025 – Dental Policy Update Bulletin: February 2025open_in_new
Last Published 02.01.2025
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Dental Clinical Policies, Coverage Guidelines, and Review Guidelines.
12/01/2024 – Dental Policy Update Bulletin: December 2024open_in_new
Last Published 12.01.2024
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Dental Clinical Policies, Coverage Guidelines, and Review Guidelines.
Dental Policy Update Bulletin Archiveopen_in_new
Last Published 02.01.2025
A listing of the Dental Policy Update Bulletins for the past two rolling years.
Current Policies & Guidelines
Dental Clinical Policies and Coverage Guidelines Terms and Conditions
Please read the terms and conditions below carefully.
UnitedHealthcare has developed Dental Clinical Policies and Dental Coverage Guidelines to assist us in administering dental plan benefits. These policies and guidelines are provided for informational purposes and do not constitute clinical advice. Treating dentists and other health care providers are solely responsible for determining what care to provide to their patients. Members should always consult their dentist or physician before making any decisions about dental or medical care.
Our Dental Clinical Policies express our determination of whether a dental service (e.g. procedure or technology) is proven to be effective based on the published clinical evidence. They are also used to decide whether a given dental service is clinically necessary. Services determined to be experimental, investigational, unproven, or not clinically necessary by the clinical evidence are typically not covered.
Dental Coverage Guidelines are used to determine whether a service falls within a benefit category or is excluded from coverage. Dental Coverage Guidelines may also address such matters as periodicity and other limitations, including whether a procedure is cosmetic, based on evidence.
Benefit coverage for dental services is determined by the member specific benefit plan document, such as a Certificate of Coverage, Schedule of Benefits, or Summary Plan Description, and applicable laws that may require coverage for a specific service. The member specific benefit plan document identifies which services are covered, which are excluded, and which are subject to limitations. In the event of a conflict, the member specific benefit plan document supersedes these policies and guidelines.
Dental Clinical Policies and Dental Coverage Guidelines are developed as needed, are regularly reviewed and updated, and are subject to change. They represent a portion of the resources used to support UnitedHealthcare coverage decision making. The information presented in these policies and guidelines is believed to be accurate and current as of the date of publication, and is provided on an "AS IS" basis. Additionally, UnitedHealthcare may use tools developed by third parties, including the American Dental Association and other peer organizations, to assist us in administering dental benefits. These third-party-guidelines are intended to be used in connection with the independent professional clinical judgment of a qualified dentist or other health care provider and do not constitute the practice of dentistry or dental advice.
Dental Clinical Policies and Dental Coverage Guidelines are the property of UnitedHealthcare. Unauthorized copying, use and distribution of this information are strictly prohibited. Third party guidelines are proprietary to the originating organization and are not published on this website.
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Application of Desensitizing Medicaments and Resins – Dental Clinical Policyopen_in_new
Last Published 11.01.2024
Effective Date: 11.01.2024 – This policy addresses application of desensitizing medicament or resin. Applicable Procedure Codes: D1206, D9910, D9911.
Bacterial, Viral, and Fungal Testing of Oral Infections – Dental Coverage Guidelineopen_in_new
Last Published 12.02.2024
Effective Date: 12.01.2024 – This policy addresses collection of microorganisms for culture and sensitivity. Applicable Procedure Codes: D0414, D0415, D0416.
Biologic Materials for Soft and Hard Tissue Regeneration – Dental Clinical Policyopen_in_new
Last Published 12.02.2024
Effective Date: 05.01.2024 – This policy addresses biologic materials for soft and hard tissue regeneration, including collection and application of autologous blood concentrate product. Applicable Procedure Codes: D4265, D4999, and D7921.
Bone Replacement Grafts – Dental Clinical Policyopen_in_new
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses bone replacement grafts for retained natural teeth and ridge preservation, and osseous, osteoperiosteal, or cartilage grafting. Applicable Procedure Codes: D3428, D3429, D4263, D4264, D7950, D7953.
Cone Beam Computed Tomography – Dental Clinical Policyopen_in_new
Last Published 12.02.2024
Effective Date: 05.01.2024 – This policy addresses cone beam computed tomography (CBCT). Applicable Procedures Codes: D0364, D0365, D0366, D0367, D0368, D0380, D0381, D0382, D0383, D0384, D0391, D0393, D0394, D0395.
Core Buildup, Post and Core, and Pin Retention – Dental Coverage Guidelineopen_in_new
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses restorative foundation for an indirect restoration, core buildup (including any pins when required), post and core, pin retention, and post removal. Applicable Procedure Codes: D2949, D2950, D2951, D2952, D2953, D2954, D2955, D2957, D2999.
Coronal Splinting – Dental Coverage Guidelineopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses provisional splinting. Applicable Procedure Codes: D4322, D4323.
Dental Barrier Membrane Guided Tissue Regeneration – Dental Clinical Policyopen_in_new
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses guided tissue regeneration with resorbable and non-resorbable barriers. Applicable Procedures Codes: D6106, D6107, D3432, D4266, D4267, D4286, D7956, D7957.
Dental Care Services in an Operating Room or Ambulatory Surgery Center – Dental Coverage Guidelineopen_in_new
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses dental care under general anesthesia in a hospital operating room (OR) or ambulatory surgery center (ASC).
Dental Implant Placement and Treatment of Peri-Implant Defects/Disease – Dental Coverage Guidelineopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses dental implants and treatment of peri-implant defects and disease.
Dental Implant Supported Prostheses – Dental Coverage Guidelineopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses dental implant supported prostheses.
Fixed Prosthodontics – Dental Coverage Guidelineopen_in_new
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses fixed partial dentures (including provisional FPD) and repair, precision attachments, connector bar, and stress breaker.
Full Mouth Debridement – Dental Coverage Guidelineopen_in_new
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses full mouth debridement. Applicable Procedure Code: D4355.
General Anesthesia and Conscious Sedation Services – Dental Coverage Guidelineopen_in_new
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses sedation for dentistry and local anesthesia, including nitrous oxide, intravenous moderate/conscious sedation, non-intravenous sedation, deep sedation/general anesthesia, and nerve blocks. Applicable Procedure Codes: D9210, D9211, D9212, D9215, D9219, D9222, D9223, D9230, D9239, D9243, D9248.
Genetic Testing for Oral Disease – Dental Clinical Policyopen_in_new
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses collection and preparation of genetic sample material for laboratory analysis and report. Applicable Procedure Codes: D0422, D0423.
In-Office Drug Administration and Dispensing of Medications – Dental Clinical Policyopen_in_new
Last Published 07.01.2024
Effective Date: 07.01.2024 – This policy addresses therapeutic parenteral drug administration (single or two or more administrations), infiltration of sustained release therapeutic drug (single or multiple sites), and drugs or medicaments dispensed in the office for home use. Applicable Procedure Codes: D9610, D9612, D9613, D9630.
Labial Veneers – Dental Coverage Guidelineopen_in_new
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses labial veneers. Applicable Procedure Codes: D2960, D2961, D2962.
Medically Necessary Orthodontic Treatment – Dental Coverage Guidelineopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses medically necessary orthodontic treatment. Applicable Procedure Codes: D8010, D8020, D8030, D8040, D8070, D8080, D8090, D8091, D8220, D8660, D8670, D8671, D8680, D8695, D8696, D8697, D8698, D8699, D8701, D8702, D8703, D8704, D8999.
Miscellaneous Diagnostic Procedures – Dental Clinical Policyopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses in-office HbA1c and blood glucose level tests, caries susceptibility tests, brush biopsies, pulp vitality tests, adjunctive pre-diagnostic tests that aid in the detection of mucosal abnormalities including premalignant and malignant lesions (not to include cytology or biopsy procedures), and diagnostic casts. Applicable Procedure Codes: D0411, D0412, D0425, D0431, D0460, D0470, D0604, D0605, D0606, D7288.
National Standardized Dental Claim Review Guidelines (for Commercial Only) – Dental Review Guidelineopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses dental claim utilization review criteria, including a list of CDT codes and their applicable documentation requirements and/or related UnitedHealthcare Dental Clinical Policies and Coverage Guidelines detailing coverage criteria.
National Standardized Dental Claim Review Guidelines (for Medicare Advantage Plans Only) – Dental Review Guidelineopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses dental claim utilization review criteria, including a list of CDT codes and their applicable documentation requirements and/or related UnitedHealthcare Dental Clinical Policies and Coverage Guidelines detailing coverage criteria for Medicare Advantage plans.
Non-Ionizing Diagnostic Procedures – Dental Clinical Policyopen_in_new
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses non-ionizing diagnostic procedures. Applicable Procedure Code: D0600.
Non-Surgical Endodontics – Dental Coverage Guidelineopen_in_new
Last Published 12.01.2024
Effective Date: 02.01.2024 – This policy addresses direct and indirect pulp cap, therapeutic pulpotomy, partial pulpectomy for apexogenesis, apexification/recalcification, pulpal regeneration, pulpal debridement, pulpal and endodontic therapies, treatment of root canal obstruction, incomplete endodontic therapy for inoperable/ unrestorable/fractured tooth, internal root repair of perforation defects, and retreatment of previous root canal therapy. Applicable Procedure Codes: D3110, D3120, D3220, D3221, D3222, D3230, D3240, D3310, D3320, D3330, D3331, D3332, D3333, D3346, D3347, D3348, D3351, D3352, D3353, D3355, D3356, D3357, D3911, D3921.
Non-Surgical Extractions – Dental Coverage Guidelineopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses non-surgical extractions. Applicable Procedure Codes: D7111, D7140.
Non-Surgical Periodontal Therapy – Dental Clinical Policyopen_in_new
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses scaling and root planning, localized delivery of antimicrobial agents, periodontal maintenance, scaling in presence of generalized moderate or severe gingival inflammation (full mouth), and gingival irrigation. Applicable Procedure Codes: D4341, D4342, D4346, D4381, D4910, D4921.
Occlusal Guards – Dental Coverage Guidelineopen_in_new
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses occlusal guards. Applicable Procedure Codes: D9942, D9943, D9944, D9945, D9946.
Oral Surgery: Alveoloplasty and Vestibuloplasty – Dental Coverage Guidelineopen_in_new
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses alveoloplasty and vestibuloplasty. Applicable Procedure Codes: D7310, D7311, D7320, D7321, D7340, D7350.
Oral Surgery: Miscellaneous Surgical Procedures – Dental Clinical Policyopen_in_new
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses oroantral fistula closure, primary closure of a sinus perforation, tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth, surgical repositioning of teeth, sinus augmentation procedures, and salivary gland and duct procedures. Applicable Procedure Codes: 21210, 21215, 30580, 41899, 42699, D7260, D7261, D7270, D7272, D7290, D7295, D7951, D7952, D7979, D7980, D7981, D7982, D7983, D7999.
Oral Surgery: Non-Pathologic Excisional Procedures – Dental Coverage Guidelineopen_in_new
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses frenulectomy, frenuloplasty, excision of hyperplastic tissue (per arch), excision of pericoronal gingiva, surgical reduction of fibrous tuberosity, transseptal fiberotomy/supra crestal fiberotomy (by report), removal of lateral exostosis (maxilla or mandible), removal of torus palatinus, and removal of torus mandibularis. Applicable Procedure Codes: D7291, D7471, D7472, D7473, D7961, D7962, D7963, D7970, D7971, D7972, D7999.
Oral Surgery: Orthodontic Related Procedures – Dental Clinical Policyopen_in_new
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses surgical placement of a temporary anchorage device (not related to distraction osteogenesis or orthognathic surgery), surgical access of an unerupted tooth, placement of a device to facilitate eruption of an impacted tooth, corticotomy (not related to distraction osteogenesis or orthognathic surgery), and mobilization of an erupted or malpositioned tooth to aid eruption. Applicable Procedure Codes: D7280, D7282, D7283, D7292, D7293, D7294, D7296, D7297, D7298, D7299, D7300, D7997.
Other Restorative Procedures – Dental Coverage Guidelineopen_in_new
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses repair/recement/rebound of single tooth indirect restorations, reattachment of tooth fragment and coping. Applicable Procedure Codes: D2910, D2915, D2920, D2921, D2971, D2975, D2980, D2981, D2982, D2983 and D2999.
Prefabricated Crowns – Dental Clinical Policyopen_in_new
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses prefabricated crowns. Applicable Procedure Codes: D2928, D2929, D2930, D2931, D2932, D2933, D2934.
Removable Prosthodontics – Dental Coverage Guidelineopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses complete and partial dentures, complete and partial denture rebase and reline procedures, interim prosthesis, overdentures, tissue conditioning, and repairs and adjustments.
Salivary Testing – Dental Clinical Policyopen_in_new
Last Published 12.01.2024
Effective Date: 12.01.2024 – This policy addresses collection, preparation and analysis of saliva sample for laboratory diagnostic testing and assessment of salivary flow by measurement. Applicable Procedure Codes: D0417, D0418, D0419.
Sealants and Preventive Resin Restorations – Dental Clinical Policyopen_in_new
Last Published 08.01.2024
Effective Date: 08.01.2024 – This policy addresses sealants and preventive resin restoration (PRR). Applicable Procedure Codes: D1351, D1352, D1353, D2991.
Single Tooth Direct Restorations – Dental Coverage Guidelineopen_in_new
Last Published 02.01.2025
Effective Date: 02.01.2025 – This policy addresses direct restorations, protective restoration, interim therapeutic restoration (primary dentition), and resin infiltration of incipient smooth surface lesions. Applicable Procedure Codes: D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394, D2410, D2420, D2430, D2940, D2990, D2999.
Single Tooth Indirect Restorations – Dental Coverage Guidelineopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses crowns, onlays, and inlays. Applicable Procedure Codes: D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2753, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2799, D2956.
Space Maintenance – Dental Coverage Guidelineopen_in_new
Last Published 12.01.2024
Effective Date: 12.01.2023 – This policy addresses space maintainers. Applicable Procedure Codes: D1510, D1516, D1517, D1520, D1526, D1527, D1551, D1552, D1553, D1556, D1557, D1558, D1575, D1999.
Surgical and Partial Extractions of Erupted Teeth and Removal of Retained Roots – Dental Coverage Guidelineopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses surgical extraction of erupted teeth and surgical removal of residual tooth roots. Applicable Procedure Codes: D7210, D7250, D7252, D7922.
Surgical Endodontics – Dental Clinical Policyopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses apicoectomy, surgical exposure of root surface(s) (without apicoectomy or repair of root resorption), retrograde filling, root amputation, intentional reimplantation, hemisection, bone graft in conjunction with periradicular surgery, biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery, and guided tissue regeneration resorbable barrier in conjunction with periradicular surgery. Applicable Procedure Codes: D3410, D3421, D3425, D3426, D3430, D3450, D3460, D3470, D3471, D3472, D3473, D3501, D3502, D3503, D3910, D3920, D3950, D3999.
Surgical Extraction of Impacted Teeth – Dental Clinical Policyopen_in_new
Last Published 01.01.2025
Effective Date: 01.01.2025 – This policy addresses surgical extraction of soft tissue impacted teeth, surgical extraction of partially bony impacted teeth, surgical extraction of completely bony impacted teeth, and coronectomy. Applicable Procedure Codes: D7220, D7230, D7240, D7241, D7251, D7259, D7922.
Surgical Periodontics: Mucogingival Procedures – Dental Coverage Guidelineopen_in_new
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses tissue graft procedures and biologic materials to aid in soft and osseous tissue regeneration. Applicable Procedure Codes: D4268, D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285, D4999.
Surgical Periodontics: Resective Procedures – Dental Clinical Policyopen_in_new
Last Published 12.01.2024
Effective Date: 04.01.2024 – This policy addresses gingivectomy/gingivoplasty, anatomical crown exposure, flap procedures, clinical crown lengthening-hard tissue, osseous surgery, mesial/distal wedge, and resective periodontal surgical procedures. Applicable Procedure Codes: D4210, D4211, D4212, D4230, D4231, D4240, D4241, D4245, D4249, D4260, D4261, D4274, D4999.
Topical Medicaments for Caries Prevention or Remineralization – Dental Clinical Policyopen_in_new
Last Published 12.01.2024
Effective Date: 05.01.2024 – This policy addresses topical application of fluoride excluding varnish, topical application of fluoride varnish, interim caries arresting medicament (silver diamine fluoride) application, and caries preventive medicament application. Applicable Procedure Codes: D1206, D1208, D1354, D1355.
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card. Dental coverage is not available in all plans.