D0145 - Oral Eval (<3 yr)
Evaluation for patient < 3 years old and counseling.
- Procedure Code
- D0145
- Category
- Diagnostic
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental 2026
- Frequency Limitation
- 2 per benefit year (1 every 6 consecutive rolling months) (rolling_12_months)
Required Claim Attachments & Pre-Submission Checklist
- Standard ADA claim form with CDT procedure code and date of service
Bill When (Allowable Clinical Criteria)
- Benefits for D0145 for a child over three years of age are considered miscoded, and the correct code should be applied.
Restrictions & Clinical Exclusions
- Infection control is included in the fee for the dental services provided. Separate fees are not billable to the patient.
- Oral evaluations are only a benefit when the elements included in the descriptor are completed.
- All services and treatment provided remotely via tele-health modalities, be they synchronous or asynchronous, must be performed by a licensed dentist or their supervised staff, acting within the scope of applicable law. Services and treatment delivered virtually are only a benefit when the elements included in the descriptor of the CDT procedure code are completed and only when they meet generally accepted clinical guidelines.
- Benefits for restorations for altering occlusion, adjusting vertical dimension, replacing tooth structure lost by attrition, erosion, abrasion, abfraction, corrosion, TMD, or for periodontal, orthodontic, or other splinting are denied, unless covered by group contract.
- D0145 includes any caries susceptibility tests (D0425) or oral hygiene instructions (D1330) on the same date. When performed on the same date as D0145, any fees for D0425 and D1330 are not billable to the patient.
- For patients under the age of three, any other comprehensive evaluation code submitted (D0150, D0160, D0180) is payable as D0145. Any fees in excess of D0145 are not billable to the patient.
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Benefit maximum or frequency limitation exceeded for procedure | Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria. |
ICD-10 Justification & Crosswalk Mappings
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|