D2160 - Amalgam (3 Surf)
Amalgam - 3 surfaces, permanent or primary.
- Procedure Code
- D2160
- Category
- Restorative
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental 2026
- Frequency Limitation
- 1 per surface in a 24-month interval (rolling_12_months)
Required Claim Attachments & Pre-Submission Checklist
- Diagnostic pre-operative radiograph showing affected tooth/area
Bill When (Allowable Clinical Criteria)
- Indicated for active dental caries or fractured tooth structure extending through enamel into dentin.
Restrictions & Clinical Exclusions
- Infection control is included in the fee for the dental services provided. Separate fees are not billable to the patient.
- 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/individual contract.
- Benefits for biomimetic restorations (e.g. Biodentine) are denied as investigational.
- For benefit purposes, local anesthesia is an integral part of the procedure being performed and additional fees are not billable to the patient.
- The fee for a restoration includes services such as, but not limited to, adhesives, etching, liners, bases, direct and indirect pulp caps, local anesthesia, polishing, occlusal adjustment, caries removal and gingivectomy on the same date of service. Fees for the procedures noted above, when performed in conjunction with a restoration, by the same dentist/dental office are not billable to the patient on the same date of service.
- Fees for the replacement of amalgam or composite restorations within 24 months are not billable to the patient if done by the same dentist/dental office. Benefits may be allowed if done by a different dentist. Special consideration may be given by report.
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 |
|---|---|---|---|---|---|
| K02.52 | Dental caries on pit and fissure surface penetrating into dentin | Dental caries | Yes (Primary) | BOTH | amalgam – three surfaces, primary or permanent indicated for Dental caries on pit and fissure surface penetrating into dentin |
| K02.51 | Dental caries on pit and fissure surface limited to enamel | Dental caries | Secondary | BOTH | amalgam – three surfaces, primary or permanent 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 | amalgam – three surfaces, primary or permanent 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 | amalgam – three surfaces, primary or permanent indicated for Dental caries on smooth surface limited to enamel |
| K02.62 | Dental caries on smooth surface penetrating into dentin | Dental caries | Secondary | BOTH | amalgam – three surfaces, primary or permanent indicated for Dental caries on smooth surface penetrating into dentin |
| K02.63 | Dental caries on smooth surface penetrating into pulp | Dental caries | Secondary | BOTH | amalgam – three surfaces, primary or permanent indicated for Dental caries on smooth surface penetrating into pulp |
| K03.81 | Cracked tooth | Other diseases of hard tissues of teeth | Secondary | BOTH | amalgam – three surfaces, primary or permanent indicated for Cracked tooth |
| S02.5XXA | Fracture of tooth (traumatic), initial encounter for closed fracture | Fracture of skull and facial bones | Secondary | BOTH | amalgam – three surfaces, primary or permanent indicated for Fracture of tooth (traumatic), initial encounter for closed fracture |