Utilization Review Guidelines

Altus Dental's Utilization Review Guidelines explain the criteria used to determine whether a procedure qualifies for coverage. The UR guidelines are organized by dental procedure code and include any documentation needed to file a claim for a particular service (for example, x-rays, periodontal charting, etc.). Note that while you may recommend a service, it may not meet the "dentally necessary" criteria specified in our UR Guidelines and we may not cover the service. Also, a service may not be covered by your patient's specific dental plan.

These guidelines are subject to change as new procedure codes are introduced, when existing codes are revised or when materials, techniques and insurance industry practices are updated. Log in to your online account to read our Utilization Review Guidelines.

Complete Claim Standard

Providing Medically Necessary Orthodontics

Coverage for medically necessary orthodontics for children under the age of 19 is a key element of the Pediatric Dental Essential Health Benefit under the Affordable Care Act.

To learn more about this benefit, click here.

Review our guidelines for medically necessary orthodontic coverage.

Scoring Form
For use in evaluating the need for medically necessary orthodontic coverage.