D1351 - Sealant (Per Tooth)
Sealant application for permanent molars/premolars.
- Procedure Code
- D1351
- Clinical Category
- Preventive
- Primary ICD-10 Justification
- K02.51 (Dental caries on pit and fissure surface limited to enamel)
- Reference Fee & Claim Types
- BOTH
Insurance Verification Benchmarks & Billing Guidelines
Payer policy benchmarks, pre-submission attachment requirements, and denial prevention rules for D1351.
- Frequency Limitation
- Once per tooth per lifetime or once every 36 months (LIFETIME_OR_INTERVAL)
- Age Limitation Criteria
- Covered through age 15 (cut off on 16th birthday). Some Medicaid plans cover through age 18.
Required Claim Attachments & Pre-Submission Checklist
- Valid tooth number specified (permanent 1st or 2nd molar)
- Patient age verified as under 16
- Tooth confirmed as unrestored and non-carious
Bill When (Allowable Clinical Criteria)
- Virgin permanent first and second molars (#2, 3, 14, 15, 18, 19, 30, 31)
- Deep developmental pits and fissures without active decay
Restrictions & Clinical Exclusions
- Do NOT bill on primary teeth or premolars (benefits almost always denied)
- Do NOT bill on teeth with existing occlusal restorations or active decay
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-35 | Age limitation exceeded or tooth previously sealed within 3 years | Verify tooth history. If tooth was restored previously, sealant is contractually non-covered. |
ICD-10-CM Justification & Crosswalk Mappings for D1351 (6)
Click any ICD-10-CM diagnosis code below to inspect its reverse procedure mappings and differential coding guide.
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|---|---|---|---|---|
| K02.51 | Dental caries on pit and fissure surface limited to enamel | Dental caries | ★ Yes (Primary) | BOTH | sealant – per tooth indicated for Dental caries on pit and fissure surface limited to enamel |
| K02.53 | Dental caries on pit and fissure surface penetrating into pulp | Dental caries | Secondary | BOTH | sealant – per tooth indicated for Dental caries on pit and fissure surface penetrating into pulp |
| K02.61 | Dental caries on smooth surface limited to enamel | Dental caries | Secondary | BOTH | sealant – per tooth indicated for Dental caries on smooth surface limited to enamel |
| K02.62 | Dental caries on smooth surface penetrating into dentin | Dental caries | Secondary | BOTH | sealant – per tooth indicated for Dental caries on smooth surface penetrating into dentin |
| K02.63 | Dental caries on smooth surface penetrating into pulp | Dental caries | Secondary | BOTH | sealant – per tooth indicated for Dental caries on smooth surface penetrating into pulp |
| M35.00 | Sjögren syndrome, unspecified | Systemic involvement of connective tissue | Secondary | BOTH | sealant – per tooth indicated for Sjögren syndrome, unspecified |
Frequently Asked Questions — D1351 (Sealant (Per Tooth))
Quick answers for dental billers and treatment coordinators submitting claims for D1351.
What ICD-10 diagnosis codes link to dental procedure D1351?▾
Common ICD-10-CM justification codes for CDT D1351 (Sealant (Per Tooth)) include: K02.51 - Dental caries on pit and fissure surface limited to enamel (Primary); K02.53 - Dental caries on pit and fissure surface penetrating into pulp; K02.61 - Dental caries on smooth surface limited to enamel; K02.62 - Dental caries on smooth surface penetrating into dentin; K02.63 - Dental caries on smooth surface penetrating into pulp; M35.00 - Sjögren syndrome, unspecified.
Can CDT code D1351 be billed to medical insurance?▾
Billing CDT D1351 (Sealant (Per Tooth)) to medical insurance depends on the underlying clinical necessity and trauma/pathology documentation. Supported claim types across linked diagnoses: BOTH.
What attachments and documentation are required for billing CDT D1351?▾
Required claim attachments for CDT D1351 (Sealant (Per Tooth)) include: Valid tooth number specified (permanent 1st or 2nd molar); Patient age verified as under 16; Tooth confirmed as unrestored and non-carious.
What is the insurance frequency limitation for CDT D1351?▾
Standard commercial insurance frequency for D1351: Once per tooth per lifetime or once every 36 months (LIFETIME_OR_INTERVAL). Age criteria: Covered through age 15 (cut off on 16th birthday). Some Medicaid plans cover through age 18..
What are common insurance denial reasons and appeal tips for CDT D1351?▾
Denial Code CO-35 (Age limitation exceeded or tooth previously sealed within 3 years): Overturn appeal strategy - Verify tooth history. If tooth was restored previously, sealant is contractually non-covered.