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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield - Maine core buildup Covera…
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    CurrentBlue Cross Blue Shield - MainePolicy 02-901

    Core Buildup - includes post and core procedures

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    Defines clinical criteria, documentation, and coding guidance for coverage of core buildups and prefabricated or indirect post-and-core procedures for dental members under the payer's dental policies.

    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyCore Buildup - includes post and core procedures
    Policy CodePolicy 02-901
    Change TypeRevised (no material clinical changes)
    Effective DateJan 1, 2025
    Last ReviewOct 25, 2024
    Next Review DateJan 1, 2025
    Key ActionSubmit current (within 12 months) diagnostic-quality radiographs and supporting documentation to demonstrate clinical necessity for prior authorization.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    16+detailed criteria points
    D2950–D2957primary CDT range

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    12 monthsradiograph timeframe
    10/25/2024last revised

    Coverage Criteria for Core Buildup and Post-and-Core

    inv-01: Covered when ALL of the following are met (posterior teeth)

    Covered for posterior teeth only when ALL of the following conditions are present:

    Posterior tooth coverage: A significant portion of missing tooth structure due to caries, fracture, or defective restoration; insufficient tooth structure coronal to the intended restorative margin for adequate retention; and a crown or retainer is either existing (to be recemented/rebonded) or is treatment planned.

    From adjunctive documentation items 3.a-3.c

    inv-02: Covered when ALL of the following are met (anterior teeth)

    Covered for anterior teeth only when ALL of the following conditions are present:

    Anterior tooth coverage: A significant portion of missing tooth structure due to caries, fracture, or defective restoration; insufficient tooth structure coronal to the intended restorative margin for adequate retention; and a crown or abutment is either existing or is treatment planned.

    From adjunctive documentation items 4.a-4.c

    inv-03: Do not cover when ANY of the following conditions are present

    Not covered when any of these exclusionary conditions apply:

    Exclusions list: Placement for pulp capping, insulation or protection of the pulp; undercut block-outs; enhancement of box-form or fillers for reduction of final restorative material; repair of complications from attrition, abrasion, erosion, or abfraction; correction of developmental or congenital defects; placement for partial coverage indirect restorations (onlays, inlays, veneers, 3/4 crowns); teeth with caries into the furcation; primary teeth without intact root structure or adequate periodontal support or without a permanent successor (or where successor is likely to erupt); teeth with uncontrolled or untreated periodontal disease with loss of supporting bone; teeth with untreated or unresolved periapical or periradicular pathology; unresolved lesions near the pulp without planned endodontic therapy; overfill/underfill root canal obturation or poor condensation; internal or external resorption; situations where subgingival/subosseous caries may compromise supracrestal tissue attachment without addressing restorative and periodontal considerations.

    Consolidated exclusion conditions from adjunctive documentation items 5,8,9,11,15-18,21

    inv-04: Primary tooth considerations

    Primary teeth considered for core buildup/post-and-core only when ALL of the following are present:

    Primary tooth: The primary tooth meets the same criteria as a permanent tooth; radiographic images demonstrate intact root structure and adequate periodontal support with no evidence of active periodontal disease; the primary tooth has occlusal function with an opposing tooth meeting criteria for full coverage indirect restoration; and radiographic imaging demonstrates no permanent tooth successor is present or the permanent successor is unlikely to erupt.

    From adjunctive documentation item 10

    This policy explicitly excludes reimbursement for procedures when the stated clinical indications are absent. Excluded scenarios include placement of a core buildup or post-and-core for pulp capping, insulation, or protection of the pulp; use as undercut block-outs or to enhance box-form/fillers to reduce final restorative material; repair of complications from attrition, abrasion, erosion, or abfraction; correction of developmental or congenital defects; and use to support partial-coverage indirect restorations (for example, onlays, inlays, veneers, or 3/4 crowns). [[Not cited in text]]

    Additionally, services are not considered when the tooth has caries extending into the furcation, shows internal or external resorption, or when endodontic status is untreated or unresolved (including overfill/underfill or poor condensation of root canal obturation). Teeth with uncontrolled or untreated periodontal disease with loss of supporting bone are also excluded. Crown-to-root ratios poorer than 1:1 create a less-than-ideal situation and may lead to denial. Coverage is similarly withheld when subgingival or subosseous caries may compromise supracrestal tissue attachment unless periodontal and restorative considerations are addressed.

    Core buildups and post-and-core procedures will not be considered for the purpose of pulp protection, pulp capping, or as simple undercut block-outs; nor are they covered when submitted solely to modify internal box-form or act as fillers to reduce the amount of final restorative material. Use of these procedures for partial-coverage indirect restorations (onlays, inlays, veneers, 3/4 crowns) is not covered.

    Contract-dependent exceptions and administrative clarifications: depending on group contracts, a core buildup may be alternated to a one-surface restoration in instances where root canal therapy is performed through a retained existing crown. For third molars, the completed crown must be in occlusal function with an opposing tooth (occluding with at least one-third of the opposing tooth) to be considered. For primary teeth, strict additional requirements apply (see primary tooth considerations).

    Coding and Procedure Codes

    CDT codesCPT
    D2950core buildup, including any pins when required
    D2952post and core in addition to crown, indirectly fabricated
    D2953each additional indirectly fabricated post - same tooth
    D2954prefabricated post and core in addition to crown
    D2957each additional prefabricated post - same tooth
    D2955post removal

    Provider Actions, Documentation & Authorization

    Billing Rule

    Benefit alternation (contract dependent) — may be alternated to a one-surface restoration

    Depending upon group contracts, a core buildup may be alternated to a one-surface restoration. Providers should verify member-specific benefits and contract language prior to treatment and prior authorization submission when applicable.

    • Affected codes: D2950 (core buildup)
    • Benefit alternation is contract dependent — confirm plan-specific coverage rules
    Prior Authorization

    Prior authorization & codes — Coverage determination requires documentation supporting clinical necessity

    Coverage determination requires documentation supporting clinical necessity. Submit pretreatment records that justify the need for a core buildup and/or post and core. Prior authorization may be required per plan; obtain authorization when indicated by member contract.

    Background

    A core buildup reconstructs coronal tooth anatomy to provide adequate retention for an extracoronal restoration (crown) when insufficient coronal tooth structure remains. It restores internal form and enables proper crown seating and retention.

    A core buildup may be performed with or without a post. Prefabricated post-and-core systems use standardized shapes and sizes; indirect (custom) post-and-core restorations are fabricated to fit the specific anatomy of the tooth. In both cases the core buildup is integral to enabling a crown or retainer that is either existing or treatment planned, and clinical documentation (radiographs, chart notes, intra-oral photos) is required when radiographic evidence alone does not clearly demonstrate the need.

    Definitions

    Core buildup — definition and brief description
    DefinitionReconstruction of coronal tooth structure when there is insufficient retention for an extracoronal restorative procedure (crown); rebuilds the internal anatomy of the tooth as prepared for a crown.
    PurposeProvides sufficient retention and form to support a crown when remaining coronal tooth structure is inadequate.
    Relationship to post-and-coreCore buildup is integral to both prefabricated and indirectly fabricated post systems and forms the foundation for post placement and crown retention.
    Prefabricated post and core — definition
    DefinitionPrefabricated post-and-core systems manufactured in standardized shapes and sizes used as part of a post-and-core restoration.
    Use with core buildup
    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyCore Buildup - includes post and core procedures
    Policy CodePolicy 02-901
    Change TypeRevised (no material clinical changes)
    Effective DateJan 1, 2025
    Last ReviewOct 25, 2024
    Next Review DateJan 1, 2025
    Key ActionSubmit current (within 12 months) diagnostic-quality radiographs and supporting documentation to demonstrate clinical necessity for prior authorization.
    SourceLink
    On This Page
    Coverage Criteria for Core Buildup and Post-and-CoreCoding and Procedure CodesProvider Actions, Documentation & AuthorizationBackgroundDefinitions
    • Include radiographs that show the indication (see documentation requirements)
    • Attach clinical chart notes and treatment plan
    Documentation Required

    Required documentation — radiograph timeframe and diagnostic requirements

    Must include current (within 12 months), dated, pretreatment, diagnostic quality radiographic image(s) that include the radiographic apex. When radiographs do not clearly demonstrate need, provide adjunctive diagnostic information such as clinical chart notes stating rationale, intra-oral photographs, or an image after removal of an existing restoration. Other acceptable documentation may include current dated 6-point periodontal charting, history of periodontal therapy, and evidence of occlusal function when applicable.

    • Radiograph timeframe: within 12 months
    • Radiograph requirement: diagnostic quality, include radiographic apex
    • When radiograph unclear: include intra-oral photos, clinical notes, or image after restoration removal
    Denial Risk

    Common denial triggers — clinical conditions that may prompt denial

    Claims may be denied if clinical criteria are not met or documentation is insufficient. Common denial triggers include: submission for protection of the pulp or enhancement of box-form (not covered), teeth with uncontrolled periodontal disease or poor crown-to-root ratio (e.g., poorer than 1:1), unresolved endodontic or periapical pathology, core/post placement for developmental defects, or use for partial coverage restorations (onlays, inlays, veneers, ¾ crowns). The diagnosis of cracked tooth syndrome, repairs for attrition/abrasion/erosion/abfraction, and subgingival/subosseous caries without addressing supracrestal tissue attachment issues may also prompt denial.

    • Not covered: core/post for pulp capping, insulation, undercut block-outs, enhancement of box-form, developmental/congenital defects
    • Denial risk if: uncontrolled periodontal disease, crown-to-root ratio poorer than 1:1, unresolved periapical pathology, internal/external resorption
    • Core/post not considered for partial coverage indirect restorations
    Used with a core buildup to restore tooth anatomy and provide retention for an extracoronal restoration.
    ManufactureOff-the-shelf components available in various standardized shapes and sizes to fit common canal anatomies.
    Indirect post and core — definition
    DefinitionCustom-fabricated post-and-core constructed to suit the specific anatomy and needs of the tooth (indirect fabrication).
    PurposeProvides a tailored fit when standardized prefabricated posts would not adequately restore form or retention.
    Relation to core buildupThe indirect post-and-core incorporates a core buildup and is fabricated to restore internal tooth anatomy for crown retention.