Maximizing Endodontic Insurance Reimbursement*

This document, combined with the attached endodontic reimbursement grid, will provide you with a tool on how to best maximize
your patient’s insurance benefits and ensure you get paid for the endodontic treatment they need. As with all insurance maximizers,
this advice is not meant in any way to dictate diagnosis or treatment of your patients, nor is it meant to take any position on the
“rightness” of any carrier’s reimbursement strategy.

For endodontic treatment, if there is any doubt what the carrier will pay, pre-authorize the treatment. If a carrier will not authorize
payment, offer patients the option to pay full contracted fees for the procedures that are not covered.

As with all treatment, the better the quality of the radiographs, intraoral photos, and clinical notes you provide outlining the clinical
necessity for and the results of the treatment provided, the higher the probability you will have of getting paid. Below are the most
commonly asked questions on endodontic reimbursement.

What pre-appointment steps and documentation are crucial to support reimbursement from the insurance carriers?
• A completed endodontic checklist, including full breakdown of benefits. Various plans within the same carrier provide vastly
different benefits.
• An accurate and complete insurance referral form. This is a straightforward but often missed requirement to secure HMO
supplemental reimbursement.
• Obtain a pre-authorization if applicable.

What general documentation are carriers looking for in order to reimburse for endodontic procedures?
• X-rays must be “textbook,” showing undeniable clinical necessity.
• Pre-op x-rays (taken on date of service) and post-op (final) x-rays must be correctly oriented and show the apex. (No cone
cuts.)
Endodontist must enter a detailed clinical narrative into the patient’s chart.
What are some reasons carriers deny (fail to reimburse) endodontic procedures?
• Poor documentation (narrative)
• Poor quality or lack of pre-op or post-op x-rays.
• No prior authorization, or incomplete or inaccurate referral form.
• Clinical necessity (carriers’ clinical opinion/review).
• Exclusions and Limitations were not reviewed prior to rendering services.
• Poor prognosis.

What is the difference between "post-op" codes D9930 – Post-Op Surgical and D0171 – Re-Eval Post-Operative Visit, and
do these apply for GP and specialists who perform them?
• D0171 could be reported when "assessing the status of a previously performed procedure," such as grafts, oral surgery,
periodontal surgery, and endodontics that require a follow-up post-operative visit.
• D9930 is the treatment of complications (post-surgical). It may not be reimbursed when performed by the same office that
provided the original surgical service.
• Both codes are universal for both GP and specialty clinicians.

What are D3221 – Pulpal Debridement and D9110 – Palliative Treatment, and when can they be used?
• When multiple visits are required to complete endodontic treatment, one of these codes can be reported on the first day.
o D3221 – Pulpal Debridement – The relief of acute pain prior to conventional root canal therapy. This procedure is
not to be used when endodontic treatment is completed on the same day.
o D9110 – Palliative Treatment – “Palliative” generally means to ease symptoms without curing the underlying
disease. Palliative treatment should not be used to describe the start of a root canal.
• If Pulpal Debridement or Palliative Treatment is paid by the carrier, root canal or root canal retreatment reimbursement
may be reduced by the amount previously paid.

How are payers processing D3911 Intra-Orifice Barrier?

• This procedure code was released 1/1/2022 and processing criteria for each payer is still being learned.
• This procedure is not replacing Final Restoration or Build Up.
• This procedure is used to report a resin seal, placed at the opening between the obturation material and temporary or final
restoration; minimizing a risk of Root Canal reinfection in the event of restoration or seal defects.
• A common limitation is that D3911 is not a benefit if final restoration is placed on the same day as endodontic treatment.
• “Inclusive” indicates that we cannot charge the patient for this procedure.

Will carriers reimburse for Incomplete Endo Therapy (D3332)?

 • D3332 is to be used when endodontic therapy is initiated but the tooth is inoperable, unrestorable, or fractured, and the
next step is extraction.
• Insurance carriers will not reimburse for root canal or root canal retreatment after reporting D3332 on the same tooth.

Will carriers reimburse for Internal Perforation Repair (D3333) in conjunction with Root Canal Therapy (D3310, D3320, and
D3330)?
• Yes. However, if the perforation is caused by the clinician, he/she must repair the defect prior to completion of the root
canal. The patient MUST be informed of perforation and the chart MUST be documented. The patient cannot be charged
for this procedure.

Will carriers reimburse for Apicoectomy (D3410, D3421, D3425, and D3426)?
• Apicoectomy treatment may not be reimbursed if performed on a tooth less than 24 months after the completion of the root
canal/retreatment. Time limitations vary.
• If the apicoectomy is performed on the same service date as a root canal/retreatment, only a portion of the apicoectomy
fee may be reimbursed.
• Reimbursement for D3410, D3421, D3425 and D3426 is highly variable. Pre-authorization is recommended.

What CDT codes can be used to report an apexification?

• Initial Visit (D3351) includes opening tooth, preparation of canal spaces, and first placement of medication and necessary
radiographs.
• Interim Visit, (D3352) in which the intra-canal medication is replaced with new medication, this visit may be skipped or
completed as many times as clinically necessary.
• Final Visit (D3353) includes removal of intra-canal medication and procedures necessary to place final root canal filling
material, including necessary radiographs. (This procedure includes the last phase of complete root canal therapy.)
• Reimbursement of root canal therapy will NOT be made in addition to apexification.

Will carriers reimburse for Post Removal (D2955)?

• D2955 – Post Removal can be considered for payment if it is a stand-alone procedure.
• The post removal procedure is typically considered inclusive to the retreatment codes by the majority of carriers.

Will carriers reimburse for Pulp Vitality (D0460)?

• Many insurance carriers will not reimburse for D0460 if performed on the same day as treatment.
• If benefit is payable, carrier will only reimburse for one per visit, not per tooth (regardless of number of teeth tested).

Will carriers reimburse for CBCT?

• Most dental insurance payers do not cover this procedure.
• Collect medical insurance cards as some medical payers may reimburse.

As with previous guidelines, there will certainly be exceptions to the recommendations provided. Carriers often will change their
positions regarding when they will or will not reimburse for treatment, thus affecting the payment of your claims. Please contact me
with any information you may have on existing or new discrepancies you find. Together, we will maximize your patient’s benefits for
the treatment he or she needs.

Stephanie Pearlman – (682) 321-4793

Director, ROC Field Partnerships

* - certain recommendations adopted from “Coding with Confidence: the ‘Go To’ Dental Insurance Guide,” Charles Blair, D.D.S. CDT-2022/2023 Edition ISBN 978-0-692-
47686-4
 Endodontic Insurance Carrier Reimbursement Grid
D0140 paid D9310 paid D3911 (Intra- Restoration Root Canal Bone Graft (3428/3429) and
Retreat after initial (RCT) Retreats (ReTX)
same day as same day as Orifice Barrier) covered on the Obstruction (3331) Membrane (3431/3432)
(3330) Molar (3346, 3347, 3348) Frequencies
Plan treatment? treatment? same day? covered? * covered?
Carrier
Type Inclusive/Charge Covered
Pt/Covered Covered % (Time between initial and (Time after previous
Yes/No Yes/No %/Inclusive/Charge Coverage Type
Benefit (Yes/No) retreat) retreatment)
Patient
AETNA (except AZ) Yes No Inclusive Yes Covered % None No Frequency Charge Pt
AETNA (AZ) Yes No Inclusive Yes Inclusive None No Frequency Charge Pt
AMERITAS No Yes Charge Pt Yes Covered % 12 Months 1 per tooth every 12 months Subject to Benefit Review
ASSURANT BENEFIT (SUNLIFE) Yes No Charge Pt Yes Charge Patient 24 Months 1 per tooth every 24 months Subject to Benefit Review
BANNER DENTAL Yes No Charge Pt Yes Covered % 6 Months 1 per tooth every 6 months Covered
BLUE CROSS/BLUE SHIELD Yes No Inclusive Subject to Review Inclusive None No Frequency BG only
BLUE SHIELD OF CA Yes No Inclusive No Charge Patient None No Frequency BG only
BLUE CROSS/BLUE SHIELD OF SC Yes No Inclusive Yes Inclusive 24 Months 1 per tooth every 24 months BG only
BOON CHAPMAN Yes No Charge Pt Yes Inclusive 12 Months 1 per tooth every 12 months Subject to Benefit Review
CARINGTON Yes No Covered Subject to Review Charge Patient 24 Months 1 per tooth every 24 months Charge Pt
CCPOA Yes No Charge Pt Yes Covered % None No Frequency Subject to Benefit Review
CIGNA Yes No Inclusive Yes Covered % 1 Month 1 per tooth per lifetime BG only
DELTA DENTAL OF AR Yes No Charge Pt Yes Inclusive 12 Months 1 per tooth every 36 months BG only
DELTA DENTAL OF AZ Yes No Charge Pt Yes Inclusive 24 Months 1 per tooth every 36 months Subject to Benefit Review
DELTA DENTAL OF CA Yes Yes Charge Pt Yes Inclusive 12 Months 1 per tooth every 24months BG only
DELTA DENTAL OF CO Yes No Charge Pt Yes Inclusive 24 Months 1 per tooth every 24 months Subject to Benefit Review
DELTA DENTAL OF GA &FL Yes No Charge Pt Yes Inclusive 12 Months 1 per tooth every 24 months BG only
DELTA DENTAL OF ID Yes No Charge Pt Yes Inclusive 24 Months 1 per tooth per lifetime Subject to Benefit Review
DELTA DENTAL OF IL Yes No Charge Pt Yes Inclusive 12 Months/Provider + 1 per tooth every 24 months BG only
DELTA DENTAL OF KS Yes No Charge Pt Yes Inclusive 24 Months/Provider + 1 per tooth every 24 months Covered
DELTA DENTAL OF LA Yes No Charge Pt Yes Inclusive 12 Months 1 per tooth every 24 months Covered
DELTA DENTAL OF MA Yes Yes Charge Pt Yes Inclusive 12 Months/Provider + 1 per tooth every 24 months BG only
DELTA DENTAL OF MI Yes Yes Charge Pt Subject to Review Inclusive 12 Months/Provider + 1 per tooth every 24 months Subject to Benefit Review
DELTA DENTAL OF MN Yes No Charge Pt Yes Inclusive 12 Months/Provider + 1 per tooth every 24 months Subject to Benefit Review
DELTA DENTAL OF MO Yes No Charge Pt Yes Inclusive 12 Months/Provider + 1 per tooth every 24 months Subject to Benefit Review
DELTA DENTAL OF NJ Yes No Charge Pt Yes Inclusive 12 Months/Provider + 1 per tooth every 24 months BG only
DELTA DENTAL OF NM Yes Yes Charge Pt Yes Inclusive 12 Months/Provider + 1 per tooth every 24 months Subject to Benefit Review
DELTA DENTAL OF OR (MODA) Yes Yes Charge Pt Yes Covered % 24 Months/Provider + No Frequency Subject to Benefit Review
DELTA DENTAL OF PA Yes No Charge Pt Yes Inclusive 12 Months/Provider + 1 per tooth every 24 months BG only
DELTA DENTAL OF TN Yes Yes Charge Pt Yes Inclusive 24 Months/Provider + No Frequency Covered
DELTA DENTAL OF SC Yes No Charge Pt Yes Inclusive 24 Months 1 per tooth every 24 months Subject to Benefit Review
DELTA DENTAL OF TX Yes Yes Charge Pt Yes Inclusive 12 Months 1 per tooth every 24 months Covered
DELTA DENTAL OF VA Yes Yes Charge Pt Yes Inclusive 12 Months/Provider + 1 per tooth every 24 months BG only
DELTA DENTAL OF WA Yes Yes Charge Pt Yes Inclusive 12 Months 1 per tooth every 24 months Covered
DELTA DENTAL TRICARE Yes No Charge Pt Yes Inclusive 48 Months 1 per tooth every 24 months Subject to Benefit Review
GEHA CONNECTION DENTAL Yes No Charge Pt Yes Charge Patient 12 Months 1 per tooth every 12 months Charge Pt
GUARDIAN No No Charge Pt Yes Covered % None 1 per tooth per lifetime Subject to Benefit Review
HPN (NV) Yes No Charge Pt Yes Charge Patient 24 Months 1 per tooth every 24 months Subject to Benefit Review
HUMANA DENTAL Yes No Charge Pt Yes Covered % 24 Months 1 per tooth every 24 months Subject to Benefit Review
HUMANA FEDERAL Yes Yes Charge Pt Subject to Review Charge Patient None No Frequency Charge Pt
LIBERTY DENTAL Yes No Charge Pt Subject to Review Covered % None No Frequency Subject to Benefit Review
METLIFE Yes No Covered Yes Covered % Subject to Review No Frequency Covered
OPERATING ENGINEERS Yes No Charge Pt Yes Covered % 24 Months 1 per tooth every 36 months BG only
PREMIER ACCESS No No Charge Pt No Charge Patient None No Frequency Subject to Benefit Review
PRINCIPAL FINANCIAL GRP Yes No Charge Pt Yes Inclusive None 1 per tooth per lifetime BG only
SOLSTICE Yes No Charge Pt Yes Covered % 12Months+1day/Provider 12mths+1day Charge Pt
UMR Yes No Charge Pt Yes Covered % None No Frequency Subject to Benefit Review
Covered Membrane covered only if
UNITED CONCORDIA (except AZ) Yes No Yes Inclusive 12Months 1 per tooth per lifetime
eligible for BG
UNITED CONCORDIA (AZ) Yes No Covered Yes Inclusive 12 Months 1 per tooth per lifetime Subject to Benefit Review
UNITED HEALTH CARE Yes No Covered Yes Covered % 12 Months 1 per tooth per lifetime BG only
*For proper documentation, if an obstructed canal is completed, please include the percentage of obstruction along with canals in the patient’s narrative note.
+ If the same provider performs the retreat within the given time frame after performing the original root canal, the carrier will not reimburse.
“Inclusive” indicates that we cannot charge the patient
“Charge Pt” – use the fee that populates in the system; this could be UCR, a specific plan fee, or zero
“Subject to Benefit Review” - initially charge the patient; may need to subsequently adjust/refund based on receipt of actual EOB

Revised 4/7/2023
 D0140 paid D9310 paid Restoration Root Canal Bone Graft (3428/3429) and
Retreat after initial (RCT) Retreats (ReTX)
same day as same day as D3911 covered on the Obstruction (3331) Membrane (3431/3432)
(3330) Molar (3346, 3347, 3348) Frequencies
Plan treatment? treatment? same day? covered? * covered?
Carrier
Type Inclusive/Charge Covered
Pt/Covered Covered % (Time between initial and (Time after previous
Yes/No Yes/No %/Inclusive/Charge Coverage Type
Benefit (Yes/No) retreat) retreatment)
Patient

AETNA HMO Yes No Inclusive Yes Covered % None No Frequency Patient Co-pay only
AETNA HMO (AZ) Yes No Inclusive No Inclusive None No Frequency Patient Co-pay only
BLUE CROSS HMO No Yes Inclusive Yes Charge Patient None No Frequency Patient Co-pay only
CIGNA HMO Yes Yes Inclusive Yes Covered % None No Frequency Patient Co-pay only
DBP/BS No No Inclusive Yes Covered % None No Frequency Subject to Benefit Review
DELTACARE No Yes Charge Pt Yes Inclusive None 1 per tooth per lifetime Covered
H GOLDENWEST No No Charge Pt Yes Charge Patient None No Frequency BG only
M HUMANA Yes No Charge Pt Yes Covered % None No Frequency Patient Co-pay only
O LIBERTY No No Charge Pt Yes Covered % None No Frequency Subject to Benefit Review
MDG Yes No Charge Pt Yes Covered % None No Frequency Subject to Benefit Review
PACIFICARE Yes Yes Charge Pt Yes Charge Patient 5 years Subject to Review Patient Co-pay only
PUD/BS Yes Yes Inclusive Yes Covered % 5 years 1 per tooth every 5 years BG only
SAFEGUARD/METLIFE Yes No Covered Yes Covered % None No Frequency BG only
UCCI HMO Yes No Covered Yes Charge Patient None 1 per tooth per lifetime BG only (depends on plan)
UDC/FORTIS/ASSURANT Yes No Charge Pt Yes Charge Patient None No Frequency Patient Co-pay only