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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield Nevada Crowns Coverage | Op…
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    CurrentBlue Cross Blue Shield - NevadaPolicy 02-701

    Crowns, Inlays, and Onlays

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    Policy governing coverage criteria, documentation, and coding for indirect restorative dental procedures (inlays, onlays, partial and full crowns) for individual teeth under the plan; applies to providers submitting claims to Blue Cross Blue Shield - Nevada.

    Policy Summary
    PayerBlue Cross Blue Shield - Nevada
    PolicyCrowns, Inlays, and Onlays
    Policy CodePolicy 02-701
    Change TypeNo material clinical or coverage changes in this revision.
    Effective Date
    Last ReviewAug 23, 2023
    Next Review Date
    Key ActionObtain and submit current (within 1 year), dated pretreatment radiographic images including the apex and supporting documentation when requesting coverage.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    32+coverage criteria items
    CDT codes

    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.

    CDT codes listed
    1 yearradiograph recency
    6-pointperiodontal chart

    Coverage and Medical Necessity Criteria

    Medical/dental necessity criteria

    Covered when ALL of the following applicable items are met (group contract dependent where noted):

    Tooth structural indication: Tooth demonstrates significant loss of coronal structure due to caries, fracture, or defective restoration (anterior: may include incisal angles; posterior: missing structure, undermined cusps or large restorations compromising function)significant loss

    Criteria 1-2

    Referral for traumatic fracture: Fractured teeth from external trauma must first be referred to the member's medical/health plan; when treated for fracture, the fracture must involve missing tooth structure that extends into dentin to be consideredextends into dentin

    Criteria 3

    Developmental/enamel defects excluded: Teeth with developmental grooves or craze lines confined to enamel do not qualify for indirect restoration coverageconfined to enamel

    Criteria 4

    Anterior post-endodontic restorations: Anterior teeth previously treated endodontically are considered for indirect restoration only if they meet the structural loss criteria (root canal therapy alone does not qualify unless significant coronal structure including incisal angles is lost)significant loss including incisal angles

    Criteria 5

    Periodontal status: Tooth must not have uncontrolled or untreated periodontal disease; when present, definitive periodontal therapy and maintenance must be documented or included in the treatment plan and will be evaluated prior to approval; current dated 6‑point periodontal charting may be requiredN/A

    Criteria 6

    Non‑covered sole indications: Requests solely for cosmetic improvement (discolored or misshapen teeth), correction of developmental/congenital defects, occlusal alterations or changes in vertical dimension, treatment of TMD, closure of contacts absent caries/fracture/defective restoration, survey/guide plane crowns for removable partial dentures, or restorative treatment for attrition/abrasion/erosion/abfraction are not coveredN/A

    Criteria 7,14,22-25,26,28,31

    Endodontic considerations: Indirect restorations will not be considered when there is untreated or unresolved periapical/periradicular pathology, unresolved caries near the pulp without planned endodontic therapy, internal/external resorption, or other endodontic contraindications; endodontic obturation should extend ideally 0.5–1.2 mm from the apical constriction with appropriate fill densityideal obturation 0.5-1.2 mm from apical constriction

    Criteria 10 a-d

    Cracked tooth syndrome requirements: Indirect restoration for cracked tooth syndrome is appropriate only when ALL of the following are documented: (a) patient symptoms with onset/frequency/duration; (b) pain on biting verified clinically; (c) oral evaluation and contributing factors; (d) diagnosis; (e) endodontic evaluation showing no irreversible pulpal involvement; (f) structural integrity adequate to restore to function; (g) no root fracture below soft tissue attachment on radiographs; (h) additional information as requested (narrative alone is insufficient)All subitems a-h must be documented

    Criteria 15 a-h

    Primary tooth in adult dentition: For a primary tooth within an adult dentition to qualify for full coverage indirect restoration, radiographs must show intact root structure, adequate periodontal support with no active periodontal disease, occlusal function with an opposing tooth, and no permanent successor present or successor unlikely to eruptN/A

    Criteria 13

    Prosthetic/splinting considerations: When splinting of indirect restorations is requested, a determination will be made whether each splinted tooth merits an indirect restoration based on all above criteriaN/A

    Criteria 21

    Additional exclusions and limitations: Benefits will not be considered when crown-to-root ratio is poorer than 1:1 without full assessment, when subgingival/subosseous caries may compromise supracrestal tissue attachment, when caries extends into the furcation, or when age/coverage limitations apply per contract; temporary/provisional crowns are considered part of the final restoration and not eligible for separate benefitN/A

    Criteria 11,12,25,27,29,32

    Indirect restorations are not covered when placed solely to repair or address non-pathologic surface loss or solely for cosmetic or occlusal-alteration reasons. Specifically, placement of crowns, inlays, or onlays for attrition, abrasion, erosion, or abfraction is not a covered benefit under most group contracts. Requests that are solely for cosmetic improvement (for example, to address discoloration or tooth shape) or to correct developmental or congenital defects will not be considered for benefit. Similarly, procedures intended primarily to effect occlusal alterations or changes in vertical dimension, to treat temporomandibular disorder, to close contacts when there is no caries/fracture/defective restoration, or to serve as survey/guide plane crowns for removable partial dentures are excluded from coverage. For third molars, crowns must be in occlusal function (occluding with at least 1/3 of an opposing tooth) to be considered, subject to group contract terms.

    Indirect restorations will not be considered when the tooth has unresolved endodontic or advanced pathologic conditions. Specifically, placement on a tooth with untreated or unresolved periapical or periradicular pathology or with an unresolved carious lesion in close proximity to the pulp without planned endodontic therapy is not eligible for benefit. Teeth with internal or external resorption, uncontrolled periodontal disease, or caries extending into a furcation are also excluded. Prior to approving an indirect restoration, the endodontic and periodontal status must be evaluated and documented; see the referenced Endodontic Therapy policy for endodontic criteria.

    Procedure Codes and Technical Coding Notes

    Covered CDT Inlays/Onlays (examples)CDT
    D2510Inlay - metallic - one surface
    D2520Inlay - metallic - two surface
    D2530Inlay - metallic - three or more surface
    D2542Onlay - metallic - two surface
    D2543Onlay - metallic - three surface
    D2544Onlay - metallic - four or more surfaces
    D2610Inlay - porcelain/ceramic - one surface
    D2620Inlay - porcelain/ceramic - two surfaces
    D2630Inlay - porcelain/ceramic - three surfaces
    D2642Onlay - porcelain/ceramic - two surfaces
    1–10 of 15
    1/2
    Covered CDT Crowns and related codes (examples)CDT
    D2662Onlay - resin-based composite - two surface
    D2663Onlay - resin-based composite - three surface
    D2664Onlay - resin-based composite - four or more surfaces
    D2710Crown - resin-based composite (indirect)
    D2712Crown - ¾ resin based composite (indirect)
    D2720Crown - resin with high noble metal
    D2721Crown - resin with predominantly base metal
    D2722Crown - resin with noble metal
    D2740Crown - porcelain/ceramic substrate
    D2750Crown - porcelain fused to high noble metal
    1–10 of 29
    1/3
    Endodontic obturation ideal fill
    Ideal obturation lengthRoot canal filling should extend as close as possible to the apical constriction — ideal 0.5–1.2 mm from the apical constriction with appropriate fill density
    Avoidable technical errorsGross overextension (>2 mm beyond canal) or underfill (short >2 mm in presence of patent canals) should be avoided
    Reference policySee Dental Policy 03-001 Endodontic Therapy for full endodontic requirements

    Provider Requirements, Prior Authorization, and Documentation

    Prior Authorization

    Prior authorization/review may be required per contract

    Prior authorization or clinical review may be required for indirect restorations (crowns, inlays, onlays) per group contract and documentation requirements; benefits are contract dependent and the plan reviews indirect restorations based on clinical criteria and submitted documentation. A list of CDT codes that commonly require prior authorization is provided in the policy for reference.

    • Plan performs review of crowns, inlays, and onlays due to contractual requirements that benefits meet contract standards.
    • Benefits are payable based on either preparation date or cementation date depending on group contract.
    Step Therapy

    Consider lower‑cost direct restorations first when appropriate

    The plan may require that lower-cost direct restorative options (amalgam or resin‑based composite) be considered before approving an indirect restoration when appropriate and contract dependent; documentation should explain why a direct restoration is not reasonable when alternatives exist.

    Background and Clinical Context

    Indirect restorations (inlays, onlays, partial and full crowns) are intended for teeth that cannot be reasonably restored with direct amalgam or resin-based composite because of extensive structural loss. Typical indications include a tooth with significant loss of coronal structure from caries, large defective restorations, fracture, or trauma where missing structure, undermined cusps, or compromised function prevent a durable direct restoration. Prior to placement, clinicians must assess periodontal and endodontic status and document that the tooth is restorable; traumatic fractures potentially covered by medical benefits should be referred appropriately. For special situations such as cracked tooth syndrome or splinting, complete documentation of symptoms, evaluation, and restorative plan is required to support the use of an indirect restoration.

    Definitions and Terminology

    Delivery date
    Definition of delivery dateThe delivery date of an indirect restoration is the date of initial cementation or bonding regardless of cement or bonding agent type
    Cement type not determinativeType of cement used (permanent or temporary) does not determine the delivery date
    Benefit/payment notePayment/date of service may be contract dependent; some group contracts pay based on preparation date instead
    Temporary/provisional crown
    Temporary/provisional crown statusA temporary or provisional crown is considered a component of the final restoration and is not eligible for a separate benefit
    Billing implicationDo not submit separate claim for provisional crown as a distinct payable service when associated with a final indirect restoration
    Policy Summary
    PayerBlue Cross Blue Shield - Nevada
    PolicyCrowns, Inlays, and Onlays
    Policy CodePolicy 02-701
    Change TypeNo material clinical or coverage changes in this revision.
    Effective Date
    Last ReviewAug 23, 2023
    Next Review Date
    Key ActionObtain and submit current (within 1 year), dated pretreatment radiographic images including the apex and supporting documentation when requesting coverage.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaProcedure Codes and Technical Coding NotesProvider Requirements, Prior Authorization, and DocumentationBackground and Clinical ContextDefinitions and Terminology
    • Indirect restoration is appropriate when the tooth cannot reasonably be restored to functionality with an amalgam or resin-based composite (contract dependent).
    • Policy notes indirect restorations may be alternated to a composite or amalgam restoration (contract dependent).
    Documentation Required

    Provide current pretreatment radiographs and supporting clinical documentation

    Submit current (within 1 year), dated, and properly identified pretreatment diagnostic radiographic images that include the radiographic apex; additional documentation such as clinical chart notes, intra‑oral photos, and a current dated 6‑point periodontal chart and history of periodontal therapy may also be required.

    • Radiographs must include the radiographic apex and be dated within one year.
    • When radiographs do not clearly show the indication, include intra‑oral photographs and clinical chart notes stating the rationale.
    • Current dated 6‑point periodontal charting and periodontal therapy history may be requested.
    Denial Risk

    Avoid placement on teeth with untreated endodontic or periodontal pathology — risk of denial

    Do not place an indirect restoration on a tooth with untreated or unresolved periapical or periradicular pathology, unresolved caries near the pulp without planned endodontic therapy, internal/external resorption, or uncontrolled periodontal disease; such placement may result in benefit denial.

    • Placement on a tooth with untreated periapical/periradicular pathology will not be considered for benefit.
    • Unresolved carious lesion close to the pulp without planned endodontic therapy is not acceptable for indirect restoration coverage.
    Denial Risk

    Do not submit crowns requested for cosmetic or excluded sole indications

    Requests for crowns solely for cosmetic reasons, correction of developmental or congenital defects, occlusal alterations/vertical dimension changes, treatment of TMD, closure of contacts absent caries/fracture/defective restoration, or for survey/guide plane crowns for removable partial dentures are not considered for benefit and may be denied.

    • Teeth that are discolored, misshapen, or have compromised cosmetics do not qualify for indirect restoration coverage.
    • Crowns placed for correction of developmental or congenital defects, occlusal alterations/vertical dimension changes, or TMD treatment do not meet criteria for benefits.
    ReferenceSee related criteria on final restoration delivery and benefit determination