The Oral Surgery questionnaire has been updated for the following codes: D7220, D7230, D7240,7241, D7252. As of 9/1/24 this new checklist will replace the previous questionnaire and will be required along with all clinical documentational when submitting a request for the above codes.

For providers who use the portal, it will be automatically attached to the case and a written copy is not required.

For mailed submissions, a printable copy is available on our website: Oral Surgery Questionnaire – Printable Version II

**Please note: This checklist has been provided as a tool to make providers aware of the DHS medical necessity criteria and the documentation required. For further information regarding criteria and documentation requirements, please reference the DHS provider manual. The checklist does not replace required clinical documentation.