Clinical Policies

Alveoloplasty (CP.DP.33) (PDF)
Removable and Fixed Appliance Therapy (ENVD.UM.CP.0036) (PDF)
Behavioral Guidance (ENVD.UM.CP.0010) (PDF)
Buildups and Posts (CP.DP.39) (PDF)
Interim Caries Arresting Medicament Application (ENVD.UM.CP.0022) (PDF)
Caries Preventive Medicament Application (CP.DP.42) (PDF)
Cleft and Craniofacial Anomalies (ENVD.UM.CP.0013) (PDF)
Frenectomy (Frenulectomy) (CP.DP.41) (PDF)
Full Mouth Debridement (CP.CP.40) (PDF)
Incision and Drainage (CP.DP.26) (PDF)
Pre-Fabricated Crowns (ENVD.UM.CP.0017) (PDF)
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) (ENVD.UM.CP.0003) (PDF)
Endodontic Treatment (ENVD.UM.CP.0020) (PDF)
Fluoride Treatment (ENVD.UM.CP.0019) (PDF)
New Technologies and New Uses of Existing Technologies (ENVD.UM.CP.0012) (PDF)
Inhalation of Nitrous Oxide_Oxygen (ENVD.UM.CP.0021) (PDF)
Occlusal Guards (ENVD.UM.CP.0034) (PDF)
Orthodontic Treatment (ENVD.UM.CP.0005) (PDF)
Prophylaxis (ENVD.UM.CP.0018) (PDF)
Dental Restorations (ENVD.UM.CP.0016) (PDF)
Single Tooth Indirect Restorations (ENVD.UM.CP.0007) (PDF)
Indirect Fixed Prosthodontic Restorations (CP.DP.37) (PDF)
Removable Prosthodontics (ENVD.UM.CP.0025) (PDF)
Required Patient Record Documentation (CP.DP.43) (PDF)
Sealants (ENVD.UM.CP.0004) (PDF)
Secondary Services to Primary Non-Covered Services (ENVD.MM.001) (PDF)
Space Maintainer (CP.DP.38) (PDF)
Therapeutic Parenteral and Infiltrated Drugs in Dentistry (ENVD.UM.CP.0015) (PDF)
Tobacco Counseling (ENVD.UM.CP.0014) (PDF)
Vestibuloplasty (ENVD.UM.CP.0035) (PDF)


Comprehensive and Periodic Oral Evaluations (ENVD.UM.CP.0001) (PDF)
Problem Focused and Limited Oral Evaluations (ENVD.UM.CP.0002) (PDF)

Excisions and Removals

Excision of Bone Tissue (CP.DP.31) (PDF)
Excision of Soft Tissue (CP.DP.30) (PDF)
Extraction of Impacted Teeth (ENVD.UM.CP.0011) (PDF)
Removal of Foreign Body (CP.DP.32) (PDF)
Removal of Residual Tooth Roots (ENVD.UM.CP.0024) (PDF)
Surgical Extraction (ENVD.UM.CP.0023) (PDF)

Non-Surgical Procedures

Non-Surgical Periodontics (ENVD.UM.CP.0006) (PDF)


Gingivectomy and Gingival Flap Surgery (CP.DP.27) (PDF)
Orthognathic Surgery (CP.DP.44) (PDF)
Osseous Surgery (CP.DP.28) (PDF)
IV Moderate Sedation, IV Deep Sedation and General Anesthesia (ENVD.UM.CP.0009) (PDF)