D1351 - Sealant (Per Tooth)
Sealant application for permanent molars/premolars.
- Procedure Code
- D1351
- Category
- Preventive
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental National / PPO Standard
- Frequency Limitation
- Once per tooth per lifetime or once every 36 months (LIFETIME_OR_INTERVAL)
- Age Limitation
- 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 Justification & Crosswalk Mappings
| 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 |