D1353 - Sealant Repair
Repair of sealant per tooth.
- Procedure Code
- D1353
- Category
- Preventive
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental 2026
- Frequency Limitation
- 1 per tooth in a 36-month interval (unrestored permanent molars only) (rolling_12_months)
- Age Limitation
- Restricted to patients under age 16 on unrestored permanent molars.
Required Claim Attachments & Pre-Submission Checklist
- Standard ADA claim form with CDT procedure code and date of service
Bill When (Allowable Clinical Criteria)
- Indicated for medically and clinically necessary treatment as documented in patient's dental record.
Restrictions & Clinical Exclusions
- Fees for repairing sealants completed on the same date of service and on the same surface as a restoration by the same dentist/dental office are considered a component of the restoration and are not billable to the patient.
- Benefits to repair sealants are denied when submitted documentation or the patient’s claims history indicates a restoration on the occlusal surface of the same tooth.
- Fees for repair or replacement of a sealant are not billable to the patient if performed within 24 months of initial placement by the same dentist/dental office.
- Benefits for repairing sealants requested 24 months or more following the initial placement are denied or covered based on group/individual contract.
- 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.
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. |
| CO-16 | Patient age exceeds policy limitation (age 15 cutoff) | Verify patient date of birth and submit documentation proving developmental delay or exceptional mixed dentition retention. |
ICD-10 Justification & Crosswalk Mappings
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|