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The Regence Group Dental Policy
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Preventive Section - Dental Prophylaxis, Adult and Child

Topic: Dental Prophylaxis, Adult and Child Date of Origin: March 1997
Section: Preventive Policy No: 08
Last Reviewed: January 2013 Last Revised:
Approved: January 2013  


IMPORTANT INFORMATION
This Dental Policy has been developed through consideration of generally accepted standards of dental practice, review of dental literature, dental necessity, and as appropriate, government approval.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of dental policy is to provide a guide to coverage. Dental policy is not intended to dictate to providers how to practice dentistry. Providers are expected to exercise their clinical judgment in providing the most appropriate care.


Description

Prophylaxis – adult (D1110):
A dental prophylaxis performed on transitional or permanent dentition which includes scaling and polishing procedures to remove coronal plaque, calculus and stains. Some patients may require more than one appointment or one extended appointment to complete a prophylaxis.

Prophylaxis – child (D1120):
Refers to a dental prophylaxis performed on primary or transitional dentition only.

Policy/Criteria
Procedures are in accordance with generally accepted standards of dental practice.

Billing for an adult verses a child prophylaxis is determined by the dentist based on the dentition of the patient.

Administrative Guidelines
Process to contract benefits.

If the dentist reports two routine dental prophylaxis on the same claim and indicates the treatment required more than one visit to complete, process each routine prophylaxis separately. Additional charges for difficult or prolonged periods of time on the same date of service are considered inclusive of the fee for a prophylaxis.

Codes Number Description
CDT
D1000-D1999  

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