2
018  
Clinical Criteria, Guidelines  
and Practice Parameters  
CLINICALDENTISTRYGUIDELINESꢀ  
PREFACE  
LIBERTY Dental Plan’s Clinical Criteria Guidelines and Practice Parameters were originally developed in 2005 and are  
subject to periodic revisions and annual review by the QMI Committee and Board of Directors. The criteria document  
was developed internally by our Dental Directors with input from participating panel general dentists and specialists.  
LIBERTY utilizes the American Dental Association’s “Dental Practice Parameters,” sound dental clinical principles,  
processes and evidence to consistently evaluate the appropriateness of dental services that require review.  
LIBERTY Dental Plan Executive Approval  
The LIBERTY Dental Plan Quality Management and Improvement Committee has reviewed and approved the Clinical  
Criteria, Guidelines and Practice Parameters.  
1
2/12/2017  
Dental Director/QMI Chair  
Date  
LIBERTY Dental Plan’s Board of Directors has reviewed and approved the Clinical Criteria, Guidelines and Practice  
Parameters as proposed by the Quality Management Committee.  
1
2/12/2017  
Executive Vice President/Board Representative  
Date  
Please note that specific Plan/Program guidelines supersede the information contained in LIBERTY’s Clinical Criteria  
Guidelines and Practice Parameters document.  
Clinical Criteria Guidelines v.20180109  
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CLINICALDENTISTRYGUIDELINESꢀ  
TABLE OF CONTENTS  
NEW PATIENT INFORMATION.................................................................................................................................................4  
CLINICAL ORAL EVALUATIONS ................................................................................................................................................4  
INFORMED CONSENT ……………………………………………………………………………………………………………………………………………………… 5  
PRE‐DIAGNOSTIC SERVICES.....................................................................................................................................................5  
DIAGNOSTIC IMAGING............................................................................................................................................................5  
TESTS, EXAMINATIONS AND REPORTS....................................................................................................................................6  
PREVENTIVE TREATMENT .......................................................................................................................................................6  
RESTORATIVE TREATMENT .....................................................................................................................................................7  
ENDODONTICS ........................................................................................................................................................................9  
PERIODONTICS....................................................................................................................................................................111  
REMOVABLE PROSTHETICS ...................................................................................................................................................16  
ORAL SURGERY......................................................................................................................................................................18  
ADJUNCTIVE SERVICES..........................................................................................................................................................19  
RETROSPECTIVE REVIEW.....................................................................................................................................................221  
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CLINICALDENTISTRYGUIDELINESꢀ  
NEW PATIENT INFORMATION  
A. Registration information should include:  
1
. Name, sex, birth date, address and telephone number, cell phone number, e‐mail address, name of employer,  
work address and telephone number, language of preference.  
2
3
4
. Name and telephone number of person(s) to contact in an emergency.  
. For minors, name of parent(s) or guardian(s) and telephone numbers, if different from above.  
. Pertinent information relative to the patient’s chief complaint and dental history, including any problems or  
complications with previous dental treatment, previous dentist/dental clinic and date of last dental examination.  
. Medical History ‐ There should be a detailed medical history form comprised of questions which require a “Yes”  
or “No” response, including:  
5
a. Patient’s current health status  
b. Name and telephone number of physician and date of last visit  
c. History of hospitalizations and/or surgeries  
d. Current medications, including dosages and indications  
e. History of drug and medication use (including Fen‐Phen/Redux and bisphosfonates)  
f. Allergies and sensitivity to medications (including antibiotics) or materials (including latex)  
g. Adverse reaction to local anesthetics  
h. History of diseases or conditions:  
i.  
Cardio‐vascular disease, including history of abnormal (high or low) blood pressure, heart attack,  
stroke, history of rheumatic fever or heart murmur, existence of pacemakers, valve replacements  
and/or stents and bleeding problems, etc.  
ii.  
iii.  
Pulmonary disorders including COPD, tuberculosis, asthma and emphysema  
Nervous disorders, including psychiatric treatment  
iv.  
v.  
vi.  
Diabetes, endocrine disorders, and thyroid abnormalities  
Liver or kidney disease, including hepatitis and kidney dialysis  
Sexually transmitted diseases  
vii.  
viii.  
Disorders of the immune system, including HIV status/AIDS  
Other viral diseases  
ix.  
x.  
Musculoskeletal system, including prosthetic joints and when they were placed  
History of cancer, including radiation or chemotherapy  
6
. Pregnancy  
a. Document the name of the patient’s obstetrician and estimated due date.  
b. Follow current guidelines in the ADA publication, Women’s Oral Health Issues.  
7
8
. The medical history form must be signed and dated by the patient or patient’s parent or guardian.  
. Dentist’s notes following up patient comments, significant medical issues and/or consultation with a physician  
should be documented on the medical history form or in the progress notes.  
9
. Medical alerts for significant medical conditions must be uniform and conspicuously located on the monitor for  
paperless records or on a portion of the chart used and visible during treatment and should reflect current  
conditions.  
1
1
0. The dentist must sign and date all baseline medical histories after review with the patient. If electronic dental  
records are used, indication in the progress notes that the medical history was reviewed is acceptable.  
1. The medical history should be updated at appropriate intervals, dictated by the patient’s history and risk factors,  
and must be documented at least annually and signed by the patient and dentist.  
CLINICAL ORAL EVALUATIONS  
A. Periodic oral evaluations (Code D0120) of an established patient may only be provided for a patient of record who  
has had a prior comprehensive examination. Periodontal evaluations and oral cancer screenings should be updated  
at appropriate intervals, dictated by the patient’s history and risk factors, and should be done at least annually.  
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CLINICALDENTISTRYGUIDELINESꢀ  
B. A problem‐focused limited examination (Code D0140) must document the issue substantiating the medical necessity  
of the examination and treatment. (MM014)  
C. An oral evaluation of a patient less than seven years of age should include documentation of the oral and physical  
health history, evaluation of caries susceptibility and development of an oral health regimen.  
D. A comprehensive oral evaluation for new or established patients (Code D0150) who have been absent from active  
treatment for at least three years or have had a significant change in health conditions should include the following:  
1
. Observations of the initial evaluation are to be recorded in writing and charted graphically where appropriate,  
including missing or impacted teeth, existing restorations, prior endodontic treatment, fixed and removable  
appliances.  
2
3
. Assessment of TMJ status (necessary for adults) and/or classification of occlusion (necessary for minors) should  
be documented.  
. Full mouth periodontal screening must be documented for all patients; for those patients with an indication of  
periodontal disease, probing and diagnosis must be documented, including a radiographic evaluation of bone  
levels, gingival recession, inflammation, etiologic factors (e.g., plaque and calculus), mobility, and furcation  
involvements.  
4
. A soft tissue/oral cancer examination of the lips, cheeks, tongue, gingiva, oral mucosal membranes, pharynx and  
floor of the mouth must be documented for all patients, regardless of age.  
E. A post‐operative office visit for re‐evaluation should document the patient’s response to the prior treatment.  
MM014)  
(
INFORMED CONSENT  
A. The dentist should have the member sign appropriate informed consent documents and financial agreements.  
B. Following an appropriate informed consent process, if a patient elects to proceed with a procedure that is not  
covered, the member is responsible for the dentist’s usual fee.  
PRE‐DIAGNOSTIC SERVICES  
A. Screening of a patient, which includes a state or federal mandate, is used to determine the patient’s need to see a  
dentist for diagnosis.  
B. Assessment of a patient is performed to identify signs of oral or systemic disease, malformation or injury and the  
potential need for diagnosis and treatment.  
DIAGNOSTIC IMAGING  
Based on the dentist’s determination that there is generalized oral disease or a history of extensive dental treatment, an  
adequate number of images should be taken to make an appropriate diagnosis and treatment plan, per current  
FDA/ADA radiographic guidelines to minimize the patient's exposure. Photographic images may also be needed to  
evaluate and/or document the existence of pathology.  
A. An attempt should be made to obtain any recent radiographic images from the previous dentist.  
B. An adequate number of initial radiographic images should be taken to make an appropriate diagnosis and treatment  
plan, per current FDA/ADA radiographic guidelines. This includes the ALARA Principle (As Low As Reasonably  
Achievable) to minimize the patient’s exposure. It is important to limit the number of radiographic images obtained  
to the minimum necessary to obtain essential diagnostic information. (MM020)  
C. The patient should be evaluated by the dentist to determine the radiographic images necessary for the examination  
prior to any radiographic survey.  
D. Intraoral – complete series (including bitewings) (Code D0210)  
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CLINICALDENTISTRYGUIDELINESꢀ  
Note: D0210 is a radiographic survey of the whole mouth, usually consisting of 14‐22 periapical and posterior bitewing  
images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone.  
1
2
. Benefits for this procedure are determined within each plan design.  
. Any benefits for periapical and/or bitewing radiographs taken on the same date of service will be limited to a  
maximum reimbursement of the provider’s fee for a complete series.  
3
4
. Any panoramic film taken in conjunction with periapical and/or bitewing radiograph(s) will be considered as a  
complete series, for benefit purposes only.  
. Decisions about the types of recall films should also be made by the dentist and based on current FDA/ADA  
radiographic guidelines, including the complexity of previous and proposed care, caries, periodontal  
susceptibility, types of procedures and time since the patient’s last radiographic examination.  
E. Diagnostic radiographs should reveal contact areas without cone cuts or overlapping, and periapical films should  
reveal periapical areas and alveolar bone.  
F. Radiographs should exhibit good contrast.  
G. Diagnostic digital radiographs should be submitted electronically when possible or should be printed on  
photographic quality paper and exhibit good clarity and brightness.  
H. All radiographs must be mounted, labeled left/right and dated.  
I. Intra or extra‐oral photographic images should only be taken to diagnose a condition or demonstrate a need for  
treatment that is not adequately visualized radiographically. (MM0350)  
J. Any patient refusal of radiographs should be documented.  
K. Radiograph duplication fees:  
1
2
. Radiographic image duplication fees are not allowed.  
. When a patient is transferred from one contracted provider to another, diagnostic copies of all radiographic  
images less than two years old should be duplicated for the second provider.  
L. Diagnostic casts (Code D0470) are only considered medically necessary as an aid for treatment planning specific oral  
conditions. (MM047)  
TESTS, EXAMINATIONS AND REPORTS  
A. Tests, examinations and reports may be required when medically necessary to determine a diagnosis or treatment  
plan for an existing or suspected oral condition or pathology. (MM041, MM047)  
B. Oral pathology laboratory procedure/report may be required when there is evidence of a possible oral pathology  
problem. (MM0472).  
PREVENTIVE TREATMENT  
A. Dental prophylaxis (Code D1110 and D1120) may be medically necessary when documentation shows that there is  
evidence of plaque, calculus or stains on tooth structures. (MM111)  
B. Topical fluoride (Codes D1206 and D1208) treatment may be medically necessary when documentation shows that  
there is evidence of the need for this preventive procedure. (MM120)  
C. A sealant (Code D1351) or preventive resin restoration (Code D1352) may be medically necessary to prevent decay  
in a pit or fissure or as a conservative restoration in a cavitated lesion that has not extended into dentin on a  
permanent tooth in a moderate to high caries risk patient. (MM135)  
D. A space maintainer (Codes D1510 – D1525) may be medically necessary to prevent tooth movement and/or  
facilitate the future eruption of a permanent tooth. (MM150)  
E. Recognizing medical conditions that may contribute to or precipitate the need for additional prophylaxis  
procedures, supported by the patient’s physician. Verify plan benefits prior to performing additional prophylaxis  
procedures in excess of plan limitations.  
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F. Interim caries arresting medicament application (Code D1354) Silver Diamine Fluoride (SDF) is an interim caries  
arresting liquid medicament clinically applied to control and prevent the further progression of active dental caries,  
and reduce dental hypersensitivity. Treatment with Silver Diamine Fluoride will not eliminate the need for  
restorative dentistry to repair function or aesthetics, but this alternative treatment allows oral health care  
professionals to temporarily arrest caries with noninvasive methods, particularly with young children that have  
primary teeth. This should be submitted on a per tooth basis.  
RESTORATIVE TREATMENT  
A. Restorative procedures for teeth exhibiting a poor prognosis due to gross carious destruction of the clinical crown  
at/or below the bone level, advanced periodontal disease, untreated periapical pathology or poor restorability are  
not covered. (MMPROG_) (MMPROGR)  
B. Amalgam Restorations (Codes D2140‐D2161)  
1
. Dental amalgam is a cavity‐filling material made by combining mercury with other metals such as silver, copper  
and tin. Numerous scientific studies conducted over the past several decades, including two large clinical trials  
published in the April 2006 Journal of the American Medical Association, indicate dental amalgam is a safe,  
effective cavity‐filling material for children and others. And, in its 2009 review of the scientific literature on  
amalgam safety, the ADA's Council on Scientific Affairs reaffirmed that the scientific evidence continues to  
support amalgam as a valuable, viable and safe choice for dental patients…”  
2
. On July 28, 2009, the American Dental Association (ADA) agreed with the U.S. Food and Drug Administration's  
(FDA) decision not to place any restriction on the use of dental amalgam, a commonly used cavity filling  
material:  
a. The procedures of choice for treating caries or the replacement of an existing restoration not involving or  
undermining the cusps of posterior teeth is generally amalgam or composite.  
b. Facial or buccal restorations are generally considered to be “one surface” restorations, not three surfaces  
such as MFD or MBD. (MMMOD)  
c. The replacement of clinically acceptable amalgam fillings with an alternative material (composite, crown,  
etc.) is considered cosmetic and is not covered unless decay or fracture of the existing filling is present.  
(MMTRT)  
d. If a dentist chooses not to provide amalgam fillings, alternative posterior fillings must be made available for  
LIBERTY patients. Any listed amalgam copayments would still apply.  
e. An amalgam restoration includes tooth preparation and all adhesives, liners and bases. (MMINC)  
f. An amalgam restoration may be medically necessary when a tooth has a fracture, defective filling or decay  
penetrating into the dentin. (MM214)  
g. An amalgam restoration should have sound margins, appropriate occlusion and contacts and must treat all  
decay that is evident. (MM241)  
C. Resin‐based Composite Restorations (Codes D2330 – D2394)  
1
. The procedures of choice for treating caries or the replacement of an existing restoration not involving or  
undermining the incisal edges of an anterior tooth is composite. Decay limited to the incisal edge only, may still  
be a candidate for a filling restoration if little to no other surfaces manifest caries or breakdown.  
. Facial or buccal restorations are generally considered to be “one surface” restorations, not three surfaces such  
as MFD or MBD. (MMMOD)  
. The replacement of clinically acceptable amalgam fillings with alternative materials (composite, crown, etc.) is  
considered cosmetic and is not covered unless decay or fracture is present. (MMTRT)  
. A resin‐based composite restoration includes tooth preparation, acid etching, adhesives, liners, bases and  
curing. (MMINC)  
. A resin‐based composite restoration may be medically necessary when a tooth has a fracture, defective filling,  
recurrent decay or decay penetrating into the dentin. (MM230) (MM231)  
. A composite restoration should have sound margins, appropriate occlusion and contacts and must treat all  
decay that is evident. (MM232)  
2
3
4
5
6
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7
. If LIBERTY determines that there is a more appropriate procedure code to describe the restoration provided,  
either number of surfaces, or material used, an alternate procedure code may be approved. (MM230M)  
(
MM232M) (MM240M) (MM241M)  
D. Restorations for primary teeth are covered only if the tooth is symptomatic, proximal to permanent teeth, or  
expected to be present for six months or longer. (MM290)  
E. For posterior primary teeth that have had extensive loss of tooth structure or when it is necessary for preventive  
reasons, the appropriate treatment is generally a prefabricated stainless steel crown or for anterior teeth, a stainless  
steel or prefabricated resin crown.  
F. A resin infiltration of an incipient smooth surface lesion (decalcification) is appropriate for smooth surface lesions  
with some or minor enameloplasty. (MM2990)  
G. Crowns ‐ Single Restorations Only (Codes D2712 – D2791)  
1
. Administrative Issues  
a. Providers may document the date of service for these procedures to be the date when final impressions are  
completed (subject to review).  
b. Providers must complete any irreversible procedure started regardless of payment or coverage and only bill  
for indirect restorations when the service is completed (permanently cemented).  
c. Crown services must be documented using valid procedure codes in the American Dental Association’s  
Current Dental Terminology (CDT).  
2
. A crown may be medically necessary when the tooth is present and:  
a. The tooth has evidence of decay undermining more than 50% of the tooth (making the tooth weak), when a  
significant fracture is identified, or when a significant portion of the tooth has broken or is missing and has  
good endodontic, periodontal and/or restorative prognoses (MM272) (MM273) (MM237R) (MM274)  
(
(
MM274E) (MM275) (MM275P) and is not required due to wear from attrition, abrasion and/or erosion  
MM2LIM).  
b. There is a significantly defective crown (defective margins or marginal decay) or there is recurrent decay.  
MM270)  
(
c. The tooth is in functional occlusion. (MM271)  
d. When anterior teeth have incisal edges/corners that are undermined or missing because of caries, a  
defective restoration or are fractured off, a labial veneer may not be sufficient. The treatment of choice may  
be a porcelain fused to base metal crown or a porcelain/ceramic substrate crown. (MM296)  
e. The tooth has a good endodontic, periodontic and restorative prognosis with a minimum crown/root ratio of  
50% and a life expectancy of at least five years. (MMPROG_)  
3
. Enamel “craze” lines or “imminent” or “possible” fractures: Anterior or posterior teeth that show a discolored  
line in the enamel indicating a non‐decayed defect in the surface enamel and are not a through‐and through  
fracture should be monitored for future changes. Crowns may be a benefit only when there is evidence of true  
decay undermining more than 50% of the remaining enamel surface, or when there is a through‐and‐through  
fracture identified radiographically or photographically, or when a portion of the tooth has actually fractured off  
and is missing. Otherwise, there is no benefit provided for crown coverage of a tooth due to a “suspected future  
or possible” fracture. (MM272)  
4
5
. Final crowns for teeth with a good prognosis should be sequenced after performing necessary endodontic  
and/or periodontal procedures and such teeth should exhibit a minimum crown/root ratio of 50%.  
. Types of Crowns  
a. When bicuspid and anterior crowns are covered, the benefit is generally porcelain fused to a base metal  
crown or a porcelain/ceramic substrate crown.  
b. When molar crowns are indicated due to caries, an undermined or fractured cusp or the necessary  
replacement of a restoration due to pathology, the benefit is usually a base metal crown.  
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c. Porcelain/ceramic substrate crowns and porcelain fused to metal crowns on molars may be susceptible to  
fracture during occlusal function. Depending on the properties of the material used, it may not be  
consistent with good clinical practice to routinely use all‐porcelain/ceramic restorations on molar teeth.  
d. Stainless steel crowns (Codes D2930 – D2933) are primarily used on deciduous teeth and only used on adult  
teeth due to a patient’s disability/inability to withstand typical crown preparation.  
6
. Crown and Bridge Unit Upgrades  
a. Plan designs limit the total maximum amount chargeable to a member for any combination of upgrades to  
$
250 per unit.  
b. Typical upgrades include:  
i. Choice of metal – noble, high noble  
ii. Porcelain on molar teeth  
iii. Based on the particular plan design, porcelain margins may be charged separately. A reasonable amount  
may be charged ($100 or less per unit). A patient signed informed consent accepting the optional nature  
and charge for this feature must be present.  
iv. Grievances involving charges for upgrades will be found in favor of the Provider’s right to charge for  
upgraded features only when a signed informed consent or treatment plan is present that meets the  
“prudent layperson” requirement for clear disclosure of the proposed upgraded features, including risks,  
benefits and alternatives. Members must have an option to access to their covered benefit as well as any  
upgraded procedures.  
. Core Buildup, including any pins when required (Code D2950), must show evidence that the tooth requires  
additional structure to support and retain a crown. (MM291)  
7
8
a. Core buildup refers to building up of coronal structure when there is insufficient retention for an extra‐  
coronal restorative procedure.  
b. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation.  
. Post and core (Code D2952 and D2954) procedures for endodontically treated teeth include buildups. By CDT  
definitions, each of these procedures includes a “core.” Therefore, a core buildup, cannot be billed with either  
Codes D2952 or D2954 for the same tooth, during the same course of treatment. (MMINC)  
a. The tooth is functional, has had root canal treatment and the tooth requires additional structure to support  
and retain a crown. (MM295) (MM299)  
b. Post and core in addition to crown (Code D2952), is an indirectly fabricated post and core custom fabricated  
as a single unit.  
c. Prefabricated post and core in addition to crown (Code D2954) is built around a prefabricated post. This  
procedure includes the core material.  
. Pin retention or restorative foundation may be medically necessary when a tooth requires a foundation for a  
restoration. (MM2951)  
0. A coping (Code D2975) or crown under a partial denture may be required when submitted documentation  
demonstrates the medical necessity of the procedure. (MM297)  
1. Repair of a restorative