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.
A listing of the Dental Policy Update Bulletins for the past two rolling years.
Current Policies & Guidelines
Dental Clinical Policies and Coverage Guidelines Terms and Conditions
Please read the terms and conditions below carefully.
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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Effective Date: 05.01.2022 – 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.
Effective Date: 08.01.2022 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.
Effective Date: 11.01.2021 – 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.
Effective Date: 07.01.2022 – 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.
Effective Date: 09.01.2022 – 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: 41899, D7280, D7282, D7283, D7292, D7293, D7294, D7296, D7297, D7298, D7299, D7300, D7997.
Effective Date: 07.01.2022 – 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.
Effective Date: 05.01.2022 – This policy addresses complete and partial dentures, complete and partial denture rebase and reline procedures, interim prosthesis, overdentures, tissue conditioning, and repairs and adjustments.
Effective Date: 11.01.2021 – 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.
Effective Date: 04.01.2022 – This policy addresses bone replacement grafts for retained natural teeth, biologic materials to aid in soft and osseous tissue regeneration, and surgical revision procedure (per tooth). Applicable Procedure Codes: D4263, D4264, D4265, D4268, D4999.
Effective Date: 06.01.2022 – This policy addresses topical application of fluoride excluding varnish, topical application of fluoride varnish, and interim caries arresting medicament (silver diamine fluoride) application. Applicable Procedure Codes: 99188, D1206, D1208, D1354.
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.
To submit new or additional clinical evidence pertaining to a specific medical policy, click here to complete a form for UnitedHealthcare Medical Policy review. Do not submit protected health information using this form. If you have questions or concerns about a specific service for a member, refer to the appropriate Benefits, Claims, or Prior Authorization/Notification process.