ModifiedBlue Cross Blue Shield - NevadaPolicy N/A

Crowns, Inlays, and Onlays (Dental indirect restorations)

Clinical policy governing coverage criteria, documentation, and coding for dental crowns, inlays, and onlays for Blue Cross Blue Shield - Nevada members; affects dental providers submitting claims for indirect restorations.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyCrowns, Inlays, and Onlays (Dental indirect restorations)

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective DateSep 6, 2024

Next Review DateJan 1, 2025

Key ActionSubmit prior authorization with current (within 12 months) dated pretreatment radiographs and documentation that the tooth meets medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30+Procedure codes included

09/06/2024Last review date

01/01/2025Next review

12 monthsRequired radiographs timeframe

Coverage Criteria for Indirect Restorations

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medical necessity criteria for indirect restorations

Covered when ALL of the following are met as applicable to tooth type and clinical situation

Anterior tooth structural loss: 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 cusp tip (canines).

Supported by policy criteria 1 and explanatory text

Posterior tooth structural loss: Posterior tooth must demonstrate 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 one or more cusps are undermined.

Supported by policy criteria 2

Fracture from external trauma: Fractured teeth from an external blow or blunt trauma must first be referred to the member's medical/health plan; when treated under dental benefits the fracture must involve missing tooth structure that extends into dentin to be considered.

Supported by policy criteria 3

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

Supported by policy criteria 4

Endodontically treated anterior teeth: Anterior teeth that have undergone root canal therapy qualify only if there is demonstrated significant loss of tooth structure including the incisal angles; endodontic therapy alone does not qualify for indirect restoration coverage.

Supported by policy criteria 5 and policy clarifications

Periodontal status: Teeth with uncontrolled or untreated periodontal disease, radiographic or chart evidence of loss of supporting bone (including furcation) or tooth mobility may not be considered unless definitive periodontal therapy/maintenance has been performed or is planned; current dated 6‑point periodontal chart and periodontal history may be requested prior to benefit determination.

Supported by policy periodontal requirements

Endodontic/periapical health: Placement will not be considered on teeth with unresolved periapical or periradicular pathology, unresolved carious lesion near the pulp without planned endodontic therapy, or internal/external resorption; refer to Endodontic Therapy policy (03-001).

Supported by endodontic status guidance

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

Supported by policy statement on provisional crowns

Cosmetic and developmental exclusions: Crowns placed solely for cosmetic reasons (discolored, misshapen, compromised cosmetics) or to correct developmental/congenital defects are not covered; crowns placed solely to alter occlusion or vertical dimension or to treat TMD are not eligible.

Supported by policy exclusion statements

Cracked tooth syndrome: Indirect restoration for cracked tooth syndrome is appropriate only when chart documents patient's oral complaints and current symptoms (onset, frequency, duration), clinical evaluation including biting pain/pressure, diagnosis, and endodontic evaluation showing no irreversible pulpal involvement; radiographs must show no root fracture below soft tissue attachment. Additional information may be requested.

Supported by cracked tooth syndrome criteria

Third molar occlusion (when applicable): For third molars, the completed crown must be in occlusal function with an opposing tooth (must occlude with at least one‑third of an opposing tooth) unless contract exceptions apply for partial denture support.

Supported by third molar occlusion threshold

Crown to root ratio and overall prognosis: Teeth with poor crown‑to‑root ratio (poorer than 1:1), active unresolved periodontal or endodontic conditions, or other factors that compromise long‑term function may be denied; treatment planning should address these issues prior to benefit determination.

Supported by policy statements on prognosis and denial risk

Coverage of indirect restorations (crowns, onlays, inlays) is based on the clinical situation and the extent of coronal tooth structure loss. Examples where an indirect restoration may be appropriate include: significant loss of anterior tooth structure from caries, fracture, or defective restoration involving one or both incisal angles or cusp tips; posterior teeth with missing tooth structure from caries, fracture, large restorations that compromise function, or undermined cusps (one or more).

Indirect restorations may be considered when a tooth has sustained a fracture from external blunt trauma that results in missing tooth structure extending into dentin; note that fractures from external trauma should be evaluated with the member’s medical plan as appropriate and the claim must document the extent of structural loss.

When treating suspected cracked tooth syndrome, an indirect restoration is appropriate only if chart documentation includes the patient’s symptoms (onset, frequency, duration), clinical findings such as pain on biting or release, a diagnosis, and an endodontic evaluation that does not indicate irreversible pulpal involvement. Radiographs must show no root fracture below the soft tissue attachment.

Periodontal and endodontic status affect coverage: teeth with uncontrolled periodontal disease, poor crown-to-root ratio, unresolved periapical or periradicular pathology, internal/external resorption, or an unresolved carious lesion adjacent to the pulp without planned endodontic therapy are not eligible until those conditions are addressed. For third molars, the completed crown must occlude with at least 1/3 of an opposing tooth to be considered.

Indirect restorations are not covered when done solely for cosmetic reasons or to correct discoloration or misshapen teeth; crowns placed for developmental or congenital defects are explicitly not covered.

Benefits will not be considered for full coverage restorations placed for occlusal alterations, changes in vertical dimension, or for treatment of temporomandibular joint disorder (TMD) or craniomandibular disorders. Similarly, restorations placed solely to alter occlusion or to manage TMD are excluded.

Other exclusions include restorations placed for attrition/abrasion/erosion/abfraction, survey crowns or guide planes for removable partial dentures, closure of contacts except when caused by caries/fracture/defective restoration, teeth with subgingival/subosseous caries that may compromise supracrestal tissue attachment without periodontal/restorative management, and teeth with caries into the furcation.

Codes and Coding Rules

Covered/Listed CDT Codes (informational)CDT

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

1–10 of 36

1/4

Additional CDT CodesCDT

D2929	Prefabricated porcelain/ceramic crown primary tooth
D2928	Prefabricated porcelain/ceramic crown - permanent tooth
D2930	Prefabricated stainless steel crown primary tooth
D2931	Prefabricated stainless steel crown permanent tooth
D2932	Prefabricated resin crown
D2933	Prefabricated stainless steel crown with resin window
D2934	Prefabricated esthetic coated stainless-steel crown primary tooth
D2971	Additional procedures to customize a crown for partial denture framework

Opposing occlusion requirement for third molars — inv-06

RequirementThird molar must occlude with at least one-third (1/3) of an opposing tooth to be considered for full-coverage indirect restoration benefits.

ContextApplies to primary teeth within adult dentition and other third molar considerations where occlusal function is required for coverage determinations.

Related policy notesOcclusal function and opposing tooth presence are required; radiographic evidence and periodontal/endodontic status also evaluated per policy.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Prior authorization may be required for indirect restorations. Documentation must demonstrate significant loss of coronal tooth structure or other clinical indications that meet coverage criteria.

Placement of an indirect restoration on a tooth with untreated or unresolved periapical or periradicular pathology is not eligible for benefit.
Placement of an indirect restoration on a tooth with an unresolved carious lesion in close proximity to the pulp chamber (without planned endodontic therapy) will not be considered for benefit.
Placement of an indirect restoration on a tooth with internal or external resorption may not be considered for benefit.

Billing Rule

Temporary/Provisional Crown Billing

Billing rule: A temporary/provisional crown is considered part of the final restoration and is not eligible for separate reimbursement.

A temporary or provisional crown is included in the final indirect restoration benefit and should not be billed separately.
The delivery date of an indirect restoration is the date of initial cementation or bonding (type of cement does not determine delivery date).

Documentation Required

Documentation Requirements

Documentation Required. Include current, dated pretreatment radiographs (within 12 months) that show the radiographic apex and clinical documentation to support the medical necessity of the indirect restoration.

Must include current (within 12 months), dated, pretreatment diagnostic radiographic image(s) that include the radiographic apex.
Clinical chart notes, intraoral photographs, and a current dated 6‑point periodontal charting and history of periodontal therapy may be required.
When radiographic findings do not clearly show the indication, include intraoral photos and clinical rationale in chart notes.

Denial Risk

Contraindications and Denial Risk

Denial Risk — Contraindications and Clinical Limits. Indirect restorations will be denied when clinical contraindications are present or required documentation is missing.

Placement on teeth with unresolved periapical/periradicular pathology is not covered.
Teeth with uncontrolled or untreated periodontal disease, significant bone loss, furcation involvement, or mobility may be excluded unless definitive periodontal therapy has been performed and documented.
Indirect restorations are not covered for teeth with active caries into the furcation or when subgingival/subosseous caries may compromise supracrestal tissue attachment without addressing restorative and periodontal considerations.
Crowns for solely cosmetic reasons, developmental/congenital defects correction, occlusal alterations/vertical dimension changes, or TMD treatment are not eligible for benefits (contract dependent).
Teeth with craze lines or enamel‑only defects do not qualify; root fractures below soft tissue attachment level are exclusions.

Revision History

2019-03-04revision

External facing policy created (version noted in history).

2019-04-22revision

Criteria numbering revised.

2019-07-03revision

Wording/terminology revisions made to policy language.

2020-08-26annual_review

Annual review completed.

2020-12-04annual_revision

Annual revision to policy document.

2021-10-06revision

Policy revised (committee review noted).

2022-10-21annual_revision

Annual revision completed.

2023-08-23annual_revision

Annual revision completed.

2024-09-06revisionLatest

Minor editorial refinements to descriptions, clinical indications, criteria, and references; intent unchanged.

OpenPayer

Crowns, Inlays, and Onlays (Dental indirect restorations)

Coverage Criteria for Indirect Restorations

Codes and Coding Rules

Provider Requirements, Prior Authorization, and Documentation

Background

Definitions

Revision History