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2024 Dental Prior Authorization List

If your 2024 Devoted Health plan offers dental coverage through Delta Dental or Liberty Dental, we always recommend that your dentist check with them before providing services — this is called a pre-treatment estimate. But for certain services, getting a pre-treatment estimate is actually required — this is called prior authorization. 

You may need prior authorization for services related to:

  • Crowns
  • Root canals
  • Gum surgery
  • Deep cleanings
  • Dentures
  • Bridges
  • Extractions and oral surgery
  • Nitrous oxide (laughing gas)
  • Nightguards

For a detailed list of the codes that require prior authorization, see the bottom of this page. 

Why do I need prior authorization for these services?
It helps Delta Dental and Liberty Dental check that their dentists are providing the care that’s right for your needs. 

My plan includes out-of-network dental coverage. Do I still need a prior authorization if I see an out-of-network dentist?
Prior authorization isn’t required for out-of-network dentists — but it’s still a good idea to ask for an estimate before you get any care. We can only pay for dental services if they’re medically necessary and your plan covers them, so having your dentist check first can help you avoid surprise costs.

Keep in mind that you may pay more if you see an out-of-network dentist. Your plan’s coverage is based on a usual amount that Devoted Health allows for each covered service. If an out-of-network dentist charges more than that amount, you’ll need to pay the difference — on top of any coinsurance. 

Codes requiring prior authorization

Here are all the codes for covered dental services that require prior authorization. For other coverage limits, see your plan’s full list of covered dental codes.

There are just a few cases where your coverage may be different:

  • Plans that only cover basic services like cleanings, fillings, and extractions: Many of the codes below aren’t covered for you. You’ll only need prior authorization for codes D4341 and D4342 (deep cleanings) and code D7210 (extractions). 
  • Florida DUAL or DUAL PLUS plans: If you have Medicaid benefits, your plan may cover some extra dental services that require prior authorization, in addition to the ones listed below. Call us for details.

Crowns

  • Cap (crown) made of metal, porcelain, porcelain fused to metal or titanium (D2740, D2750, D2752, D2753, D2790, D2792, D2794)
  • Buildup filling that is placed to prepare a tooth for a new cap (crown) (D2950)
  • Custom-made post and buildup filling that is usually fabricated by a dental lab, placed after a root canal to prepare the tooth for a cap (crown) (D2952)
  • Pre-made post and buildup filling that is not fabricated by a dental lab, placed after a root canal to prepare tooth for a cap (crown) (D2954)

Root canals

  • Initial root canal on a front, middle or back tooth (D3310, D3320, D3330)
  • Root canal retreatment (redo) on a front, middle or back tooth (D3346, D3347, D3348)

Gum surgery

  • Surgical procedures that treat periodontal disease (gum disease) to promote healing of gums and underlying bone (D4210, D4211, D4240, D4241, D4260, D4261)

Deep cleanings

  • Deep cleaning that’s performed to remove bacteria, plaque and tartar below the gumline along the tooth roots (D4341, D4342)

Complete dentures

  • Complete upper denture (for patients missing all their upper teeth) (D5110)
  • Complete lower denture (for patients missing all their bottom teeth) (D5120)
  • Complete upper denture that is delivered on the same day of extracting remaining upper teeth. This denture is meant to be temporary and is called an immediate complete upper denture (D5130)
  • Complete lower denture that is delivered on the same day of extracting remaining lower teeth. This denture is meant to be temporary and is called an immediate complete lower denture (D5140)

Partial dentures

  • Upper partial denture (for patients missing some of their upper teeth) (D5211, D5213, D5225)
  • Lower partial denture (for patients missing some of their lower teeth) (D5212, D5214, D5226)
  • Upper partial denture that is delivered on the same day of extracting some upper teeth. This denture is meant to be temporary and is called an immediate upper partial denture (D5221, D5223, D5227)
  • Lower partial denture that is delivered on the same day of extracting some lower teeth. This denture is meant to be temporary and is called an immediate lower partial denture (D5222, D5224, D5228)
  • Unilateral removable partial denture for the upper or lower arch. This is a ‘quadrant’ denture meant to only replace 1-2 missing teeth. (D5284, D5286)

Bridges

  • The fake tooth (pontic) of the bridge that replaces the missing tooth (edentulous space). Pontics are made of metal, porcelain, porcelain fused to metal or titanium (D6210, D6212, D6214, D6240, D6242, D6243, D6245)
  • The caps (retainers) of the bridge that are placed on natural teeth. Retainers are made of metal, porcelain, porcelain fused to metal or titanium (D6545, D6548, D6740, D6750, D6752, D6753, D6790, D6792, D6794)

Extractions and oral surgery

  • Routine or surgical extractions of erupted teeth or exposed roots (D7210, D7250)
  • Reshaping of bone at extraction site(s) in preparation for a denture procedure (alveoloplasty) (D7310, D7311)
  • Removal of malignant tumor in the upper or lower jaw (D7440, D7441)

Nitrous oxide (laughing gas)

  • Nitrous Oxide (laughing gas) sedation (D9230)

Nightguards

  • Top or bottom hard nightguard that is used to protect the teeth from clenching and/or grinding (D9944)