Blue Cross Blue Shield FEP Dental
General Services
General Services
Miscellaneous Services
D9941 Fabrication of athletic mouthguard – Limit 1 every 12 months
D9943 Occlusal guard adjustment - Limit 1 every 6 months for patients 13 and older
D9944 Occlusal guard – hard appliance, full arch – Limit 1 every 12 months for patients 13 and older
D9945 Occlusal guard – soft appliance, full arch – Limit 1 every 12 months for patients 13 and older
D9946 Occlusal guard – hard appliance, partial arch – Limit 1 every 12 months for patients 13 and older
D9974 Internal bleaching - per tooth
D9999 Unspecified adjunctive procedure, by report
General Services Notes:
D9943 Occlusal guard adjustment - Limit 1 every 6 months for patients 13 and older
D9944 Occlusal guard – hard appliance, full arch – Limit 1 every 12 months for patients 13 and older
D9945 Occlusal guard – soft appliance, full arch – Limit 1 every 12 months for patients 13 and older
D9946 Occlusal guard – hard appliance, partial arch – Limit 1 every 12 months for patients 13 and older
D9974 Internal bleaching - per tooth
D9999 Unspecified adjunctive procedure, by report
General Services Notes:
- Deep sedation/general anesthesia and intravenous sedation are covered when provided in conjunction with covered surgical procedures. The services must be rendered by a dentist licensed and approved to provide anesthesia in the state where rendered.
- Deep sedation/general anesthesia and intravenous sedation are covered when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifiable conditions.
- In order for deep sedation/general anesthesia and intravenous conscious sedation to be covered, submission must include the procedure for which it was necessary.