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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield Nevada crowns coverage upda…
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    CurrentBlue Cross Blue Shield - NevadaPolicy 02-701

    Crowns, Inlays, and Onlays

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    Governs indications, documentation, and coverage determination for indirect restorative dental procedures (inlays, onlays, partial and full crowns) for members of Blue Cross Blue Shield - Nevada according to group contract provisions and clinical criteria.

    Policy Summary
    PayerBlue Cross Blue Shield - Nevada
    PolicyCrowns, Inlays, and Onlays
    Policy CodePolicy 02-701
    Change TypeNo material change
    Effective Date
    Last ReviewOct 21, 2022
    Next Review DateOct 21, 2022
    Key ActionSubmit current (within 1 year) pretreatment radiographs and supporting documentation for prior authorization when required.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    32coverage criteria items
    D2510-D2971example CDT ranges

    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.

    1 yr
    radiograph recency
    2022-10-21last review

    Coverage Criteria for Indirect Restorations

    Medical necessity criteria

    Covered when ALL of the following are met (subject to group contract provisions):

    Structural loss indication: Tooth demonstrates significant loss of coronal tooth structure due to caries, fracture, or defective restoration; anterior teeth may involve one or both incisal angles or cusp tip, and posterior teeth may have loss of cusp support or large restorations undermining cusps.significant loss

    See criteria 1-2 for anterior/posterior specifics

    Trauma origin: Fractured teeth from an external blow or blunt trauma must first be referred to the member's medical/health plan; if dental benefit is considered, the fracture must involve missing tooth structure that extends into dentin.extends into dentin

    Medical plan review required for accidental injury claims

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

    Cosmetic-only conditions are not covered

    Periodontal status: Teeth must not demonstrate uncontrolled or untreated periodontal disease (radiographic or periodontal charting evidence); definitive periodontal therapy and maintenance must be performed or planned and will be evaluated prior to approval; a current dated 6-point periodontal chart may be requested.controlled periodontal health

    Consider mobility, bone loss, furcation involvement

    Endodontic considerations: No unresolved periapical or periradicular pathology or unresolved carious lesion near the pulp without planned endodontic therapy; endodontic obturation should approximate the apical constriction (ideal 0.5–1.2 mm) with avoidance of gross overextension or underfill (>2 mm); internal or external resorption may preclude benefit.no unresolved pathology

    See Dental Policy 03-001 Endodontic Therapy

    Cosmetic and other exclusions: Indirect restorations placed solely for cosmetic reasons (discolored, misshapen, compromised esthetics), correction of developmental/congenital defects, occlusal alterations/vertical dimension changes, treatment of TMD/craniomandibular disorders, or for sole purpose of survey/guide planes for removable partial dentures are not covered.n/a

    Some exclusions are group contract dependent

    Other limitations: Indirect restorations for repair of attrition/abrasion/erosion/abfraction, closure of contacts (unless due to caries/fracture/defective restoration), subgingival/subosseous caries that may compromise supracrestal tissue attachment, or caries into the furcation will not be considered for benefit.n/a

    Group contract dependent for some items

    Cracked Tooth Syndrome

    Special condition: Cracked tooth syndrome must meet ALL of the following documented items:

    Cracked tooth documentation: a) Chart documentation of the patient's oral complaints and current symptoms including onset, frequency, and duration; b) symptoms including pain or discomfort upon biting (or release of biting) or pressure verified by clinical exam; c) oral examination and any contributing factors recorded; d) the diagnosis documented in the chart; e) endodontic evaluation demonstrating no irreversible pulpal involvement necessitating endodontic therapy; f) structural integrity adequate to restore the tooth to function; g) radiographic images show no vertical or horizontal root fracture below the soft tissue attachment level; h) additional information may be requested and a narrative alone is not sufficient.all present and documented

    Chart documentation is required; narrative alone is insufficient

    Primary tooth in adult dentition

    Primary tooth in adult dentition:

    Primary tooth criteria: Radiographic images must demonstrate intact root structure, adequate periodontal support with no evidence of active periodontal disease, occlusal function with an opposing tooth, and either absence of a permanent successor or a permanent successor unlikely to erupt.radiographic confirmation

    Group contract dependent

    Operational considerations

    Additional operational rules:

    Temporary crown: A temporary or provisional crown is considered a component of the final restoration and is not eligible for a separate benefit.n/a

    Delivery date is considered the date of initial cementation or bonding regardless of cement type

    Replacement for metal allergy: Replacement requests attributed to metal allergy or sensitivity will be considered only upon submission of physician documentation with the associated allergy report.physician documentation and allergy report

    Additional documentation may be requested

    Indirect restorations are subject to specific exclusions. Crowns, inlays, and onlays placed solely for cosmetic reasons—including treatment of teeth that are only discolored, misshapen, or have compromised esthetics—are not covered. Crowns placed for the correction of developmental or congenital defects are excluded. Restorations intended to effect occlusal alterations or changes in vertical dimension, or those placed to treat temporomandibular joint (TMJ)/craniomandibular disorders, do not meet criteria for benefit. Additionally, indirect restorations provided solely as survey crowns or guide planes for removable partial dentures (RPDs) are not covered, and restorations to repair complications from attrition, abrasion, erosion, or abfraction are also excluded.

    Fractures resulting from external blunt trauma or an accidental blow should first be evaluated under the member’s medical/health plan. If dental benefit determination is required, the fracture must involve missing tooth structure that extends into the dentinal layer for an indirect restoration to be considered. Group contract provisions may affect whether benefits apply.

    Minor enamel-only defects do not meet medical necessity for indirect restorations. Teeth with developmental grooves or craze lines confined to enamel do not qualify, and crowns placed solely to address discoloration, minor misshaping, or other cosmetic concerns are considered not medically necessary.

    Relevant CDT Codes and Examples

    CDT Inlay/Onlay examplesCDT
    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
    CDT Crown/Onlay examplesCDT
    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

    Prior Authorization, Documentation, and Provider Requirements

    Prior Authorization

    Prior Authorization and Benefit Determination

    Prior authorization may be required for indirect restorations (crowns, inlays, onlays). Benefits are determined by group contract terms and must meet clinical criteria with supporting documentation. Submit pretreatment documentation and any requested adjunctive records to allow benefit determination.

    • Prior authorization requirements vary by group contract.
    • Benefits are contract dependent and require clinical justification.
    Documentation Required

    Conservative Treatment Preference

    Conservative restorations (amalgam or resin-based composite) are preferred when they can reasonably restore form and function. Indirect restorations (including crowns) are indicated when there is significant structural loss from decay, fracture, or trauma and conservative treatment is not sufficient. Replacement solely for survey/guide plane purposes, cosmetic reasons, or correction of developmental defects is not a covered benefit unless contract language specifies otherwise.

    Background and Clinical Context

    Indirect restorations (inlays, onlays, and crowns) are indicated when a tooth’s coronal structure is extensively compromised and cannot be predictably restored with an amalgam or resin-based composite. Typical clinical situations include extensive caries, a large defective restoration, or a fracture that undermines cuspal support or involves incisal angles. Prior to placement, the tooth’s periodontal and endodontic status must be evaluated—unresolved periapical or periodontal disease, significant root pathology, or inadequate tooth structure for restoration may preclude benefit. Temporary/provisional crowns are considered part of the final restoration and are not eligible for separate payment.

    Key Definitions and Dates

    Delivery date — definition entry for indirect restoration
    TermDelivery date of an indirect restoration
    DefinitionThe delivery date is considered the date of initial cementation or bonding of the permanent indirect restoration.
    Cement typeType of cement or bonding agent (permanent or temporary) does not determine the delivery date.
    Contract variationPayment or adjudication date of service may be contract dependent (preparation date vs cementation date).
    Temporary crownsTemporary/provisional crowns are considered part of the final restoration and not eligible for a separate benefit.
    Delivery/cementation date — policy definition
    Policy Summary
    PayerBlue Cross Blue Shield - Nevada
    PolicyCrowns, Inlays, and Onlays
    Policy CodePolicy 02-701
    Change TypeNo material change
    Effective Date
    Last ReviewOct 21, 2022
    Next Review DateOct 21, 2022
    Key ActionSubmit current (within 1 year) pretreatment radiographs and supporting documentation for prior authorization when required.
    SourceLink
    On This Page
    Coverage Criteria for Indirect RestorationsRelevant CDT Codes and ExamplesPrior Authorization, Documentation, and Provider RequirementsBackground and Clinical ContextKey Definitions and Dates
    • Indirect restorations are considered when tooth cannot be restored with direct restoratives.
    • Crowns placed solely as survey/guide planes, for cosmetics, or to treat TMD are generally not covered.
    Documentation Required

    Required Diagnostic Documentation

    Required diagnostic documentation must be submitted with requests for indirect restorations. Documentation must be current (within 1 year), dated, and properly identified.

    • Pretreatment radiographic images that include the radiographic apex (dated within 1 year).
    • Clinical chart notes stating the rationale for the indirect restoration.
    • Intra-oral photographs when radiographs do not clearly demonstrate the indication.
    • Current dated 6-point periodontal charting and history of periodontal therapy when relevant.
    Documentation Required

    Cracked Tooth Syndrome Documentation

    For cracked tooth syndrome, document the diagnostic and treatment rationale fully in the chart notes. An indirect restoration is appropriate only when all required diagnostic elements are met and recorded.

    • Chart documentation of patient's complaints and current symptoms including onset, frequency, and duration.
    • Documentation of symptoms provoked by biting or release of biting, and pressure verified by clinical exam.
    • Oral examination findings and any contributing factors.
    • Clear diagnostic statement of cracked tooth syndrome.
    • Endodontic evaluation showing no irreversible pulpal involvement requiring endodontic therapy.
    • Evidence that structural integrity allows restoration to function (no unrecoverable tooth structure loss).
    • Radiographic evidence demonstrating no root fracture (vertical or horizontal) below the soft tissue attachment level.
    Documentation Required

    Metal Allergy Documentation

    Requests to replace indirect restorations for metal allergy or sensitivity require medical documentation from a physician.

    • Submit physician documentation and the associated allergy report when replacement is due to metal allergy/sensitivity.
    • Replacement for metal allergy will be considered only upon receipt of appropriate medical evidence.
    Denial Risk

    Endodontic Status Contraindications

    Do not place indirect restorations on teeth with unresolved endodontic or periodontal pathology or active caries that compromise prognosis. Endodontic status must be appropriate before considering an indirect restoration.

    • Indirect restorations on teeth with untreated or unresolved periapical or periradicular pathology will not be considered for benefit.
    • Indirect restorations on teeth with unresolved carious lesions in close proximity to the pulp are not eligible unless endodontic therapy is planned.
    • Teeth with internal or external resorption may not be considered for benefit.
    • Endodontic obturation should extend close to the apical constriction with appropriate density; extreme overextension or underfill may preclude benefit.
    Key statementDelivery/cementation date is the date of initial cementation or bonding regardless of cement type.
    Cement irrelevanceWhether a permanent or temporary cement is used does not change the delivery date determination.
    Benefit implicationThe date for benefit payment may still vary by group contract (e.g., preparation date vs cementation date).
    Related considerationEndodontic and periodontal status must be acceptable prior to placement of the indirect restoration.