CurrentBlue Cross Blue Shield - NevadaPolicy 02 -701

Crowns, Inlays, and Onlays Guideline

Defines clinical and documentation criteria used by the plan to determine medical/dental necessity for indirect restorations (inlays, onlays, partial and full crowns) for single teeth, including exclusions, documentation requirements, and contract-dependent provisions. Coding list (CDT) provided for informational use only.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyCrowns, Inlays, and Onlays Guideline

Policy CodePolicy 02 -701

Change TypeRevised (historical revisions through 10/06/2021)

Effective DateJan 1, 2022

Next Review Date

Key ActionProviders must include current (within 1 year), dated, and properly identified pretreatment radiographic images including the radiographic apex; if indication not obvious, include intra-oral photographs and clinical chart notes stating the rationale.

SourceLink

POLICY UPDATE CHANGES

Policy status noted as Revised; multiple historical revision entries with dates through 10/06/2021 (annual revisions).

~30+CDT codes listed (informational)

MultipleCriteria items

Coverage Summary

Overview: Crowns, Inlays, and Onlays (indirect restorative procedures) — Policy #02 -701. This clinical UM guideline defines criteria and documentation requirements used to determine medical/dental necessity for indirect restorations (inlays, onlays, partial and full crowns) for single teeth. Effective date: 01/01/2022. Status: Revised / CURRENT.

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Medical Necessity Criteria

General medical necessity criteria for indirect restorations

Covered when ALL of the following are met:

ALL of the following

Tooth structural indications: Tooth exhibits significant loss of coronal tooth structure due to caries, fracture, or defective restoration; for anterior teeth may include involvement of one or both incisal angles or cusp tip (canines).
Posterior tooth demonstrates 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).
Group contract dependent structural loss: Tooth structural loss from decay, fracture, or trauma must be present (group contract dependent).
Endodontic status: Placement on a tooth with untreated or unresolved periapical or periradicular pathology will not be considered; placement on a tooth with unresolved carious lesion near the pulp without planned endodontic therapy is not considered; internal or external resorption may not be considered. (See Dental Policy 03-001 Endodontic Therapy.)
Root fracture exclusion: Teeth with root fracture (vertical or horizontal) below soft tissue attachment level are excluded.
Structural integrity of the tooth must not be compromised beyond the point of being able to restore the tooth to function.
Periodontal health must be considered: uncontrolled or untreated periodontal disease, radiographic or chart evidence of 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.
Documentation: Must include current (within 1 year), dated, properly identified pretreatment radiographic images that include the radiographic apex. If indication is not obvious on radiograph, include intra-oral photographs and clinical chart notes with rationale.

Provider Actions & Documentation Requirements

Documentation Required

Submit pretreatment radiographs and supporting documentation

Providers must include current (within 1 year), dated, and properly identified pretreatment radiographic images including the radiographic apex. If the indication is not obvious on the radiograph, include intra-oral photographs and clinical chart notes stating the rationale.

Radiograph taken within 1 year
Radiograph must include the radiographic apex
Include intra-oral photos and clinical chart notes when indication is unclear

Documentation Required

Periodontal documentation may be required

Submit current dated 6-point periodontal charting, history of periodontal therapy, and evidence of periodontal maintenance when periodontal disease may affect eligibility for indirect restorations.

Current dated 6-point periodontal charting
History of periodontal therapy
Evidence of periodontal maintenance

Prior Authorization

Plan review required (utilization review)

The plan performs review of crowns, inlays, and onlays to determine whether services meet contract and generally accepted standards. Contact the customer service number on the member's card to determine if a guideline review (utilization review) is required for a given case.

Billing Rule

Temporary crowns not separately reimbursable

Temporary or provisional crowns are considered a component part of the final restoration and are not eligible for separate benefit; affected code: D2799.

Affected code: D2799

Denial Risk

Denial risk for untreated pathology or inadequate documentation

Claims can be denied if there is untreated pathology or inadequate documentation. Ensure endodontic and radiographic status and required documentation are complete before submission.

Untreated periapical or periradicular pathology
Unresolved caries near the pulp without planned endodontic therapy
Insufficient radiographs (not current or lacking apex)
Missing periodontal charting or intra-oral photographs when requested

Documentation Required

Metal allergy replacement documentation

Replacement of indirect restorations for metal allergy or sensitivity will be considered only when physician documentation and the associated allergy report are submitted.

Background

Background: This guideline is a clinical utilization management tool to assess dental necessity and conformity with group contract requirements for indirect restorative procedures. It emphasizes that benefits are reviewed to ensure services meet generally accepted standards of dental care at the lowest cost that properly addresses the patient's condition. The plan/contract implementation and payment rules may vary by line of business or group contract.

STA (supracrestal tissue attachment): Formerly referred to as biologic width; subgingival/subosseous caries that may potentially compromise the STA may preclude benefit unless restorative and periodontal considerations are addressed.

Revision History

3/4/19revision

Revised (external facing policy) as listed in the revision history.

4/22/19revision

Revised (criteria numbering) as listed in the revision history.

7/3/19revision

Revised (verbiage) as listed in the revision history.

8/26/20revision

Revised (annual review) as listed in the revision history.

12/4/20revision

Revised (annual revision) as listed in the revision history.

10/06/2021revisionLatest

Revised (annual revision) as listed in the revision history. Changes noted as non-material.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyCrowns, Inlays, and Onlays Guideline

Policy CodePolicy 02 -701

Change TypeRevised (historical revisions through 10/06/2021)

Effective DateJan 1, 2022

Next Review Date

SourceLink

On This Page

D2510	Inlay - metallic one surface
D2520	Inlay - metallic two surface
D2530	Inlay - metallic three or more surfaces
D2542	Onlay - metallic two surface
D2543	Onlay - metallic three surface
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

Crowns, Inlays, and Onlays Guideline

Coverage Summary

Medical Necessity Criteria

Coding (informational)

Provider Actions & Documentation Requirements

Background

Revision History