Blue Cross Blue Shield FEP Dental
General Services

D9941 Fabrication of athletic mouthguard –Limit 1 every 12 months

D9943 Occlusal guard adjustment - Limit 1 every 6 months for patients 13 and older

D9944 Occlusal guard – hard appliance, full arch – Limit 1 every 12 months for patients 13 and older

D9945 Occlusal guard – soft appliance, full arch – Limit 1 every 12 months for patients 13 and older

D9946 Occlusal guard – hard appliance, partial arch – Limit 1 every 12 months for patients 13 and older

D9974 Internal bleaching - per tooth

D9999 Unspecified Adjunctive procedure, by report

General Services Notes:

• Deep sedation/general anesthesia and intravenous sedation are covered when provided in conjunction with covered surgical procedures. The services must be rendered by a dentist licensed and approved to provide anesthesia in the state where rendered.
   
• Deep sedation/general anesthesia and intravenous sedation are covered when determined to be medically or dentally necessary for documented handicapped or uncontrollable patients or justifiable conditions.
   
• In order for deep sedation/general anesthesia and intravenous conscious sedation to be covered, submission must include the procedure for which it was necessary.