Covered when ALL of the following apply as specified below (contract dependent in many items):
General coverage premise: To be eligible for an indirect restoration benefit, the tooth must demonstrate significant loss of coronal tooth structure from caries, fracture, defective restoration, or trauma (fracture from external blow should be referred first to the member's medical/health plan).
Fractures must involve missing tooth structure extending into dentin; see anterior/posterior specifics.
Anterior tooth criteria: An anterior tooth must demonstrate significant loss of coronal tooth structure due to caries, fracture, or defective restoration and/or involvement of one or both incisal angles or a cusp tip (canine).
An anterior tooth that has had root canal therapy alone does not qualify unless significant structural loss including incisal angles is demonstrated.
Posterior tooth criteria: A posterior tooth must demonstrate significant missing tooth structure from caries, fracture, or defective restoration and/or large restorations that compromise function, or loss of cusp support where one or more cusps are undermined.
Cracked tooth syndrome requires specific documentation (see cracked tooth node).
Endodontic status: There must be no untreated or unresolved periapical or periradicular pathology; placement on teeth with unresolved carious lesions in close proximity to the pulp without planned endodontic therapy will not be considered. Endodontic evaluation must show no irreversible pulpal involvement necessitating endodontic therapy.
See Dental Clinical Policy 03-001 Endodontic Therapy; obturation and other endodontic criteria may be applied.
Periodontal status: Teeth with uncontrolled or untreated periodontal disease (radiographic bone loss including furcation involvement, tooth mobility) may not be considered unless definitive periodontal therapy and maintenance have been successfully performed or are planned and will be evaluated prior to approval.
Current dated 6-point periodontal chart and history of periodontal therapy may be requested prior to benefit determination.
Structural integrity and radiographic findings: Tooth must not have a root fracture (vertical or horizontal) below the soft tissue attachment on radiographs; when a tooth is too damaged to be restored for adequate function, benefit will be denied.
Additional information may be requested; narratives alone are not considered appropriate review material.
Cracked tooth syndrome requirements: Indirect restoration is appropriate only when all of the following are documented: symptoms (onset, frequency, duration); pain on biting verified by clinical evaluation; oral evaluation including contributing factors; endodontic evaluation showing no irreversible pulpal involvement; and radiographs demonstrating no root fracture below the soft tissue attachment. Documentation must be provided in chart notes; narratives alone are insufficient.
The plan may request additional information as appropriate for clarification.
Excluded or contract-dependent exclusions: Indirect restorations placed for repair of attrition/abrasion/erosion/abfraction, solely cosmetic reasons (discoloration, misshape, compromised cosmetics), to treat TMD or occlusal alterations, as survey crowns/guide planes for removable partial dentures, for developmental/congenital defects, or when crown-to-root ratio is poorer than 1:1 may be denied or are excluded depending on contract. Benefits are not considered for closure of contacts unless caused by caries, tooth fracture, or defective restoration, or when subgingival/subosseous caries may compromise supracrestal tissue attachment without addressing restorative and periodontal considerations.
Many of these items are contract dependent and may be denied.