Delta Dental of Virginia's Clinical Policies

Delta Dental of Virginia’s clinical policies are developed to assist in administering plan benefits. The clinical policies define our standard guidelines to determine whether certain procedures are dentally necessary based upon available clinical documentation. Delta Dental of Virginia’s clinical policies are updated on a regular basis and, therefore, subject to change.

Diagnostic

#001 Collection of Microorganisms for Culture and Sensitivity

Restorative

#200 Placement of Full Crown Restorations
#201 Post and Core Placement
#202 Core Buildup and Pin Retention
#203 Inlay and Onlay Restorations
#204 Labial Veneers

Periodontic

#400 Bone Grafts
#401 Gingivectomy
#402 Mucogingival Surgery and Soft Tissue Grafting
#403 Biological Materials to Aid in Soft and Osseous Tissue Regeneration
#404 Osseous Surgery
#405 Periodontal Maintenance
#406 Guided Tissue Regeneration
#407 Scaling and Root Planing
#408 Local Delivery of Antimicrobial Agents
#409 Clinical Crown Lengthening
#410 Full Mouth Debridement
#411 Gingival Flap Surgery

Prosthodontic (Removable)

#500 Removable Partial Dentures

Prosthodontic (Fixed)

#600 Placement of Fixed Partial Dentures
#601 Placement of Dental Implant

Oral and Maxillofacial Surgery

#700 Extraction of Teeth (Routine and Surgical)
#701 Oral Brush Biopsy
#702 Alveoloplasty
#703 Frenulectomy (Frenectomy or Frenotomy) and Frenuloplasty
#704 Biopsy and Surgical Excision of Soft and Hard Tissue Lesions
#705 Prophylactic Removal of Third Molar Teeth

Endodontic

#800 Endodontics

Adjunctive General Services

#900 General Anesthesia
#901 Palliative (Emergency) Treatment of Dental Pain-Minor Procedure