CurrentAnthemPolicy 02 -701

Dental Clinical Policy

This dental clinical policy defines documentation requirements, indications, exclusions, and clinical criteria for coverage determination of indirect restorations (inlays, onlays, crowns) and addresses contract-dependent limitations (e.g., accidental injury referral, cosmetic exclusions, periodontal and endodontic considerations). It also provides applicable CDT codes for reference.

Policy Summary

PayerAnthem

PolicyDental Clinical Policy

Policy CodePolicy 02 -701

Change TypeMinor editorial refinements

Effective Date

Next Review DateOct 1, 2026

Key ActionProvide current (within 12 months), dated, pretreatment radiographic image(s) including the radiographic apex; if not definitive, include intraoral photos and clinical chart notes explaining indication.

SourceLink

POLICY UPDATE CHANGES

Minor editorial refinements to description, clinical indications, criteria, and reference; intent unchanged (noted 10/01/2025).

Multiple prior revisions and annual reviews from 2019 through 2024 documented; 09/06/2024 noted minor editorial refinements.

24+Referenced CDT procedure codes

MultipleConditional / contract-dependent provisions

SeveralDocumented exclusion categories

Coverage summary and scope

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This policy defines documentation requirements, clinical indications, exclusions, and coverage determination criteria for indirect restorations including inlays, onlays, and crowns. It addresses contract-dependent limitations such as medical plan referral for trauma-related fractures, cosmetic exclusions, periodontal and endodontic considerations, and other operational rules. Effective/last review and next review dates: Last review: 01/01/2026; Revision noted: 10/01/2025; Next review: 10/01/2026.

Key thresholds and definitions

Radiograph currencywithin 12 months

Delivery date (definition)Date of initial cementation or bonding of the permanent indirect restoration; type of cement (permanent or temporary) does not change delivery date determination.

Occlusal function for third molar crownsCompleted crown must occlude with at least 1/3 of an opposing tooth (exceptions for prosthesis support may apply).

Indirect restoration (definition)Restoration (inlay, onlay, crown) fabricated outside the mouth and cemented or bonded to the tooth.

General coverage criteria for indirect restorations (inlays/onlays/crowns)

Covered when ALL of the following are met:

Radiographic/diagnostic documentation: Radiographic and diagnostic documentation: current (within 12 months), dated, pretreatment diagnostic radiographic image(s) that include the radiographic apex must be included. If radiographic evidence is not definitive, additional diagnostic information (intraoral photos and clinical chart notes stating rationale) must accompany the image.radiograph within 12 months

Clinical chart notes, intra-oral photographs, and current dated 6-point periodontal charting may be required.

Anterior tooth indication: Anterior tooth: significant loss of coronal tooth structure due to caries, fracture, or defective restoration and/or involvement of one or both incisal angles or cusp tip (canines).significant loss as documented

An anterior tooth with root canal therapy alone does not qualify unless significant structural loss including incisal angles is demonstrated.

Posterior tooth indication: Posterior tooth: significant missing tooth structure due to caries, fracture, or defective restoration and/or large restorations that compromise function, or loss of support for the cusps where cusps are undermined (one or more cusps).significant missing structure documented

A tooth must exhibit significant structural loss from decay, fracture, or trauma (contract dependent).

Delivery date (for benefit consideration) is the date of initial cementation or bonding of the permanent indirect restoration; type of cement (permanent vs temporary) does not change delivery date determination.delivery date = cementation/bonding date

Periodontal status must be considered: uncontrolled/untreated periodontal disease, loss of supporting bone including furcation may preclude benefit unless definitive periodontal therapy and maintenance have been successfully performed or are included in the treatment plan with evaluation prior to approval. Current, dated 6-point periodontal chart may be required.may request 6-point charting

Definitive periodontal therapy and maintenance may be required prior to approval.

Endodontic status: placement on teeth with untreated or unresolved periapical or periradicular pathology will not be considered. Placement on teeth with unresolved carious lesion near the pulp without planned endodontic therapy will not be considered. Placement on teeth with internal or external resorption may not be considered. For anterior teeth: if endodontic therapy was performed, indirect restoration may be considered only if criteria for significant loss of tooth structure are met; root canal therapy alone does not qualify without significant structural loss including incisal angles.no unresolved periapical/periradicular pathology

See Endodontic Therapy policy for obturation expectations.

Cracked tooth syndrome

CTS - symptoms and documentation: Chart documentation of patient's oral complaints and current symptoms including onset, frequency and duration.
CTS - biting pain: Symptoms including pain/discomfort upon biting (or release of biting), pressure verified by clinical evaluation.
CTS - evaluation: Include oral evaluation and any contributing factors; the diagnosis must be documented.
CTS - endodontic evaluation: Endodontic evaluation showing no irreversible pulpal involvement necessitating endodontic therapy.
CTS - structural integrity:

Non-covered / Exclusion criteria

Not covered when ANY of the following apply:

Enamel-only defects: Teeth with developmental grooves or craze lines confined to the enamel only (do not qualify).enamel-only

Wear-related repairs: Indirect restorations placed for repair of complications from attrition, abrasion, erosion, or abfraction (not a covered benefit; contract dependent).

Contract dependent.

Cosmetic purposes: Indirect restorations placed for cosmetic purposes are not covered.

Developmental/congenital defects: Crowns placed for correction of developmental or congenital defects are not covered.

Occlusal alterations/TMD: Indirect restorations placed for occlusal alterations and/or changes in vertical dimension or for treatment of temporomandibular joint disorder (TMD) or craniomandibular disorders do not meet criteria and will not be considered.

Contract dependent.

Survey crowns/guide planes: Indirect restorations placed for sole purpose of functioning as survey crowns or guide planes for a removable partial denture are not covered.

Contacts closure: Benefits will not be considered for closure of contacts unless caused by caries, tooth fracture, and/or defective restoration.

Subgingival caries/STA: Benefits will not be considered when subgingival/subosseous caries may potentially compromise supracrestal tissue attachment (STA) without addressing restorative and periodontal considerations.

STA concerns must be addressed.

Untreated periapical pathology: Placement of indirect restoration on a tooth with untreated or unresolved periapical or periradicular pathology will not be considered.

See Endodontic Therapy policy.

Unresolved caries near pulp: Placement of an indirect restoration on a tooth with an unresolved carious lesion in close proximity to the pulp chamber in the absence of planned endodontic therapy will not be considered.

Internal/external resorption: Placement of an indirect restoration on a tooth with internal or external resorption may not be considered.

Metal allergy replacements: Indirect restorations placed for repair due to metal allergy/sensitivity are considered only with submission of physician documentation and associated allergy report (i.e., not routinely covered).physician documentation required

Accidental injury requirements and operational considerations

Accidental injury / medical referral requirement

Special handling for trauma-related fractures:

Medical plan referral for trauma: Claims for fractured teeth resulting from an external blow or blunt trauma must first be referred to the subscriber/employee's medical/health plan.refer to medical plan first

Most health plans include coverage for dental services related to accidental injury.

Dentinal involvement requirement: If a tooth is treated for fracture, the fracture must involve missing tooth structure that extends into the dentinal layer.fracture extends into dentin

Additional operational/contract-dependent considerations

Temporary crowns: Temporary/provisional crowns are considered component parts of the final restoration and are not eligible for a separate benefit.

Primary tooth in adult dentition: For a primary tooth within an adult dentition to be considered for full coverage, radiographic images must show intact root structure, adequate periodontal support, occlusal function with an opposing tooth, and either no permanent successor or a successor unlikely to erupt.radiographic evidence of intact root and no successor or unlikely to erupt

Splinting of indirect restorations: When splinting of indirect restorations is requested, a determination will be made whether the splinted teeth merit indirect restorations on their own right based on all criteria above (contract dependent).

Third molar crowns: For third molar teeth, the completed crown must be in occlusal function with an opposing tooth (must occlude with at least 1/3 of an opposing tooth); exceptions may apply for crowns supporting removable or fixed partial dentures (contract dependent).occlude with at least 1/3 of opposing tooth

Exceptions contract dependent.

Crown-to-root ratios poorer than 1:1 require full-mouth assessment and consideration of medical/dental/periodontal factors.poorer than 1:1 requires assessment

Assessment must include full-mouth condition, medical/dental history, periodontal history and age.

Age limitations & alternation: Age limitations for indirect restorations and alternation to composite or amalgam restorations are contract dependent.

Furcation/caries considerations: Benefits for indirect restorations will not be considered when the tooth exhibits caries into the furcation without addressing restorative/periodontal considerations.

Prior Authorization

Medical plan referral for trauma-related fractures

Refer claims for fractured teeth resulting from an external blow or blunt trauma to the subscriber/employee's medical/health plan prior to dental benefit determination.

Documentation Required

Submit diagnostic radiograph(s)

Provide current (within 12 months), dated, pretreatment diagnostic radiographic image(s) that include the radiographic apex. If the radiographic evidence is not definitive, include intraoral photographs and clinical chart notes stating the rationale/indication. Radiograph currency: within 12 months.

Documentation Required

Periodontal documentation when indicated

Provide current dated 6-point periodontal charting and history of periodontal therapy when periodontal disease or support is a concern. Demonstrate definitive periodontal therapy and maintenance if the tooth was previously diseased; current periodontal status and history may be requested prior to benefit determination.

Documentation Required

Metal allergy replacement

For replacement due to metal allergy/sensitivity, submit physician documentation and the associated allergy report for consideration.

Billing Rule

Temporary crowns

Temporary or provisional crowns are considered component parts of the final restoration and are not eligible for a separate benefit.

Revision history and document changes

10/01/2025revisedLatest

Minor editorial refinements to description, clinical indications, criteria, and reference; intent unchanged (noted 10/01/2025).

09/06/2024revised

Minor editorial refinements to description, clinical indications, criteria, and (historical entry).

08/23/2023revised

Annual Revision (historical entry).

10/21/2022revised

Annual Revision (historical entry).

10/06/2021revised

Annual Revision (historical entry).

12/04/2020revised

Annual Revision (historical entry).

08/26/2020revised

Annual Review (historical entry).

07/03/2019revised

Verbiage change (historical entry).

04/22/2019revised

Criteria numbering change (historical entry).

03/04/2019revised

External facing policy (historical entry).

D2510	Inlay - metallic - one surface
D2520	Inlay - metallic - two surfaces
D2530	Inlay - metallic - three or more surface
D2542	Onlay - metallic - two surfaces
D2543	Onlay - metallic - three surfaces
D2544	Onlay - metallic - four or more surfaces
D2610	Inlay - porcelain/ceramic - one surface
D2620	Inlay - porcelain/ceramic - two surfaces
D2630	Inlay - porcelain/ceramic - three surfaces
D2642	Onlay - porcelain/ceramic - two surfaces

OpenPayer

Dental Clinical Policy

Coverage summary and scope

General coverage criteria for indirect restorations (inlays/onlays/crowns)

Non-covered / Exclusion criteria

Accidental injury requirements and operational considerations

Referenced CDT procedure codes

Background and key references

Revision history and document changes