D1575 - Distal Shoe Mant
Distal shoe space maintainer - fixed unilateral.
- Procedure Code
- D1575
- Category
- Preventive
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental 2026
- Frequency Limitation
- 1 per quadrant per lifetime except under unusual circumstances (lifetime)
- Age Limitation
- Restricted to children under age 9. Denied for children age 9 and older.
Required Claim Attachments & Pre-Submission Checklist
- Diagnostic pre-operative radiograph showing affected tooth/area
- Pre-operative treatment narrative and clinical rationale
Bill When (Allowable Clinical Criteria)
- Indicated for premature loss of primary teeth to preserve space for eruption of succedaneous permanent teeth.
Restrictions & Clinical Exclusions
- Benefits for the repair or replacement of a space maintainer are denied.
- Only one space maintainer is benefited per arch, per lifetime except under unusual circumstances. Otherwise, benefits are denied.
- Space maintainers for missing primary anterior teeth or missing permanent teeth or for persons age 14 or older are not covered benefits and are denied.
- only one unilateral space maintainer is benefited per quadrant, per lifetime except under unusual circumstances. Otherwise, benefits are denied.
- Benefits for D1575 for children age 9 and over are denied.
- Fees for repairs and adjustments by same dentist/dental office 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. |
| CO-16 | Patient age exceeds policy limitation (age 8 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 |
|---|