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.
Last Published 09.01.2024
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Dental Clinical Policies, Coverage Guidelines, and Utilization Review Guidelines.
Last Published 10.01.2024
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Dental Clinical Policies, Coverage Guidelines, and/or Utilization Review Guidelines.
Last Published 11.01.2024
This bulletin provides complete details on recently approved, revised, and/or retired UnitedHealthcare Dental Clinical Policies, Coverage Guidelines, and Utilization Review Guidelines.
Last Published 11.01.2024
A listing of the Dental Policy Update Bulletins for the past two rolling years.
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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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.
Last Published 02.01.2024
Effective Date: 12.01.2023 – This policy addresses collection of microorganisms for culture and sensitivity and viral culture. Applicable Procedure Codes: D0414, D0415, D0416.
Last Published 05.01.2024
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.
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.
Last Published 05.01.2024
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.
Last Published 05.01.2024
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.
Last Published 11.01.2024
Effective Date: 02.01.2024 – This policy addresses provisional splinting. Applicable Procedure Codes: D4322, D4323.
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.
Last Published 05.01.2024
Effective Date: 05.01.2024 – This policy addresses dental care under general anesthesia in a hospital operating room (OR) or ambulatory surgery center (ASC).
Last Published 02.01.2024
Effective Date: 01.01.2024 – This policy addresses dental implants and treatment of peri-implant defects and disease.
Last Published 02.01.2024
Effective Date: 11.01.2023 – This policy addresses dental implant supported prostheses.
Last Published 02.01.2024
Effective Date: 12.01.2023 – This policy addresses fixed partial dentures (including provisional FPD) and repair, precision attachments, connector bar, and stress breaker.
Last Published 10.01.2024
Effective Date: 10.01.2024 – This policy addresses full mouth debridement. Applicable Procedure Code: D4355.
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.
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.
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.
Last Published 09.01.2024
Effective Date: 09.01.2024 – This policy addresses labial veneers. Applicable Procedure Codes: D2960, D2961, D2962.
Last Published 02.01.2024
Effective Date: 11.01.2023 – This policy addresses medically necessary orthodontic treatment. Applicable Procedure Codes: D8010, D8020, D8030, D8040, D8070, D8080, D8090, D8220, D8660, D8670, D8680, D8695, D8696, D8697, D8698, D8699, D8701, D8702, D8703, D8704, D8999.
Last Published 11.01.2024
Effective Date: 12.01.2023 – 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.
Last Published 11.01.2024
Effective Date: 01.01.2024 – 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.
Last Published 11.01.2024
Effective Date: 02.01.2024 – 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.
Last Published 11.01.2024
Effective Date: 02.01.2024 – This policy addresses non-ionizing diagnostic procedures. Applicable Procedure Code: D0600.
Last Published 02.01.2024
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.
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses non-surgical extractions. Applicable Procedure Codes: D7111, D7140.
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.
Last Published 04.01.2024
Effective Date: 04.01.2024 – This policy addresses occlusal guards. Applicable Procedure Codes: D9942, D9943, D9944, D9945, D9946.
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.
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.
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.
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.
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.
Last Published 04.01.2024
Effective Date: 04.01.2024 – This policy addresses prefabricated crowns. Applicable Procedure Codes: D2928, D2929, D2930, D2931, D2932, D2933, D2934.
Last Published 06.01.2024
Effective Date: 06.01.2024 – This policy addresses complete and partial dentures, complete and partial denture rebase and reline procedures, interim prosthesis, overdentures, tissue conditioning, and repairs and adjustments.
Last Published 02.01.2024
Effective Date: 11.01.2023 – 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.
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.
Last Published 07.01.2024
Effective Date: 07.01.2024 – 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, D2941, D2990, D2999.
Last Published 04.01.2024
Effective Date: 04.01.2024 – 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.
Last Published 02.01.2024
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.
Last Published 11.01.2024
Effective Date: 04.01.2024 – 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.
Last Published 02.01.2024
Effective Date: 02.01.2024 – This policy addresses surgical extraction of erupted teeth and surgical removal of residual tooth roots. Applicable Procedure Codes: D7210, D7250, D7922.
Last Published 02.01.2024
Effective Date: 12.01.2023 – 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, D7922.
Last Published 04.01.2024
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.
Last Published 04.01.2024
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.
Last Published 05.01.2024
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.