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DPAP 216

CDT Codes Requiring Narratives

Provider Administrative Policy

Policy Date
August 2013
New/August 2013
Provider Type(s)
All Providers  


Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Blue Cross of Idaho works diligently on behalf of our members to develop contracting relationships with Idaho dental providers and Blue Cross Blue Shield dental affiliates (national Dental Grid).



CDT Codes Requiring Narratives

Blue Cross of Idaho requires a narrative be included when submitting a claim for the following CDT codes. We will deny claims received without the required information and include a message code indicating, "We cannot make a final benefit determination until we receive the narrative report for your patient."

CDT Code Description
D0160 Detailed and extensive oral evaluation-problem focused, by report

Unspecified diagnostic procedure, by report

D2990 Resin infiltration of incipient smooth surface lesions
D2999 Unspecified restorative procedure, by report
D3999 Unspecified endodontic procedure, by report
D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth
D4999 Unspecified periodontal procedure, by report
D5899 Unspecified removable prosthodontic procedure, by report
D5999 Unspecified maxillofacial procedure, by report
D6090 Repair implant supported prosthesis, by report
D6199 Unspecified implant procedure, by report
D6980 Fixed partial denture repair necessitated by restorative material failure
D6999 Unspecified fixed prosthodontic procedure, by report
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla-autogenous or nonautogenous, by report
D7999 Unspecified oral surgery procedure, by report
D8999 Unspecified orthodontic procedure, by report
D9110 Palliative (emergency) treatment of dental pain-minor procedure
D9940 Occlusal guard, by report
D9999 Unspecified adjunctive procedure, by report

Policy History

Date Action Reason

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