If there is an extenuating circumstance not evident from the documentation listed below, a narrative and any available corroborating diagnostics must be submitted. As part of the re-review process Delta Dental may require documentation (e.g. photographs) in addition to that listed in these charts.

All radiographs are pretreatment unless otherwise indicated. Any radiograph submitted must be of diagnostic quality and substantiate the need and appropriateness of the service submitted for predetermination or payment. In order to do so, the dentist may need to submit radiographs in addition to those listed in these charts.

All procedures listed on these charts are not necessarily covered benefits, and all benefits are not necessarily listed.

Unless otherwise noted:

Yes = Documentation Required
Blank = Documentation Not Required
PA = Periapical Radiograph (may require more than one for diagnostic purposes)
FMX = Full Mouth Series
Pano = Panorex
DDPNJ = Delta Dental of New Jersey

ADA CDT-2005	Description	X-ray(s)	Perio Chart	Med EOB	Other
D2335	Resin-based composite-four or more surfaces or involving incisal angle (anterior)	PA
D2390	Resin-based composite crown, anterior	PA
D2510-D2792	Inlays, onlays and crowns	PA
D2799	Provisional crown	PA			Narrative
D2950	Core buildup, including any pins	PA
D2952-D2953	Cast post and core in addition to crown and each additional cast post - same tooth	PA
D2954 & D2957	Prefabricated post and core in addition to crown and each additional prefabricated post - same tooth	PA
D2960-D2962	Labial veneers	PA
D2975	Coping	PA
D2980	Crown repair, by report				Narrative
D2999	Unspecified restorative procedure, by report				Narrative