CurrentBlue Cross Blue Shield - WisconsinPolicy 04-206

Clinical Crown Lengthening

Policy governing when clinical crown lengthening is considered medically/dentally appropriate for members and what documentation/criteria are required for coverage determinations; applies to providers submitting dental claims to the plan.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyClinical Crown Lengthening

Policy CodePolicy 04-206

Change TypeNo material change

Effective DateJan 1, 2021

Next Review Date

Key ActionSubmit a diagnostic radiograph and supporting records for coverage review documenting <3 mm of sound natural tooth structure between the restorative margin and alveolar crest.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 weeksminimum healing time prior to final restoration

<3 mmradiographic threshold

natural onlynatural teeth only

inclusiveinclusive with osseous surgery

D4274 incl.D4274 with D4249

Coverage Criteria for Clinical Crown Lengthening

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyClinical Crown Lengthening

Policy CodePolicy 04-206

Change TypeNo material change

Effective DateJan 1, 2021

Next Review Date

Key ActionSubmit a diagnostic radiograph and supporting records for coverage review documenting <3 mm of sound natural tooth structure between the restorative margin and alveolar crest.

SourceLink

On This Page

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Medically/dentally necessary crown lengthening

Covered when ALL of the following are met

Primary indications: 1) Margin of proposed restoration would violate the periodontal attachment apparatus; 2) Diagnostic radiograph documents less than three millimeters of sound natural tooth structure between restorative margin and the alveolar crest (or other records if radiograph not definitive); 3) Procedure performed in a periodontally healthy environment; 4) Procedure is for a natural tooth and not for cosmetic reasons; 5) Not performed to treat non-restorative structural loss (wear/erosion/attrition/abrasion/abfraction); 6) When subgingival caries or fracture requires removal of soft and hard tissue to enable restoration; 7) A minimum of 6 weeks healing must be allowed prior to final restoration; 8) Procedure requires removal of hard (osseous) and soft tissue and may alter crown-to-root ratio — must not result in inadequate crown-to-root ratio compromising long-term prognosis.

Not medically necessary / elective scenarios

Not covered / not considered medically necessary when ANY of the following apply

Exclusions: 1) Performed for cosmetic reasons; 2) Performed for congenital or developmental defects (elective); 3) Performed on teeth with structural loss due to wear, erosion, attrition, abrasion, or abfraction; 4) Performed in conjunction with periodontal treatment for unhealthy periodontal tissues within the same quadrant on the same date of service (such procedures are not considered separately); 5) If bone removal results in inadequate crown-to-root ratio compromising prognosis; 6) Performed on non-natural (non‑natural) teeth.

Procedure and coding inclusions/exclusions

Coding inclusivity rules

Inclusive code rules: 1) If distal or proximal wedge (D4274) is performed with D4249 on the same date of service, D4274 is considered inclusive; 2) Troughing of soft tissue for crown preparation or margin visualization does not meet the descriptor for D4249; 3) If crown lengthening is performed on the same date of service as the crown, D4249 is considered inclusive with the crown; 4) When performed with osseous surgery for periodontal disease, crown lengthening is inclusive with osseous surgery; 5) Periodontal pocket charting may be required as supporting documentation.

Clinical crown lengthening is not covered when performed for purely cosmetic reasons, including procedures done to address appearance rather than restorative necessity. The policy also excludes crown lengthening for correction of congenital or developmental defects, which are considered elective. Additionally, crown lengthening is not considered appropriate for teeth with structural loss due to wear, erosion, attrition, abrasion, or abfraction and will not be allowed in those circumstances.

When crown lengthening is performed in conjunction with osseous resection, the policy requires consideration of the resulting crown-to-root ratio. If the amount of bone removal produces an inadequate crown-to-root ratio that compromises the tooth’s long-term prognosis, the procedure is not considered to provide benefit and is not appropriate. The policy further specifies that crown lengthening is allowed only for natural teeth and is not permitted when done for cosmetic purposes.

Coding and Radiographic/Timing Standards

CDT codes mentioned / referencedCDT

D4249	Clinical crown lengthening
D4274	Distal or proximal wedge procedure

Radiographic tooth structure gap — requirement: < 3 millimeters between restorative margin and alveolar crest

Radiographic thresholdDiagnostic radiograph must document less than 3 millimeters of sound natural tooth structure between the restorative margin and the alveolar crest.

Alternative recordsWhen indications are not evident radiographically, additional patient records may be requested to document need for treatment.

Applies to natural teeth onlyClinical crown lengthening will be considered for treatment of natural teeth only.

Healing interval — minimum healing time before final restoration

Minimum healing intervalA minimum of 6 weeks must be allowed for healing of bone and soft tissue prior to final restoration.

Purpose of healing intervalHealing period allows for stabilization of bone and gingival tissues after removal of hard and soft tissue.

Documentation of readinessProviders should ensure clinical and radiographic evidence of adequate healing before proceeding with final restoration.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization / Coverage Review

Prior authorization/coverage review requires submission of a diagnostic radiograph and supporting records demonstrating the clinical need for crown lengthening.

Submit diagnostic radiograph documenting relationship of restorative margin to alveolar crest
Additional patient records may be requested when indications are not evident radiographically
Periodontal pocket charting may be required

Note

Provider Action / Alert

Providers: when radiographs do not clearly demonstrate indications, be prepared to supply additional records (clinical notes, periodontal charting, photos) to support the request.

Documentation Required

Required Documentation

Required documentation: a diagnostic radiograph must document less than 3 mm of sound natural tooth structure between the restorative margin and the alveolar crest to support crown lengthening.

Radiograph must show < 3 mm of sound natural tooth structure between restorative margin and alveolar crest
Procedure appropriate only when subgingival caries or fracture requires removal of soft and hard tissue to enable restoration

Denial Risk

Inadequate Crown-to-Root Ratio

Inadequate crown-to-root ratio: if the planned bone removal for crown lengthening results in an inadequate crown-to-root ratio that compromises the long-term prognosis of the tooth, the procedure is not considered beneficial and will not be approved.

Crown lengthening requires alteration of crown-root ratio; denial risk if resulting ratio compromises prognosis
Clinical crown lengthening may only be performed in a periodontally healthy environment

Denial Risk

Cosmetic or Inappropriate Indications

Cosmetic or inappropriate indications: crown lengthening performed for cosmetic reasons, treatment of structural loss due to wear/erosion/attrition/abrasion/abfraction, or procedures on non-natural teeth are not covered.

Not covered when performed for cosmetic reasons
Not covered for teeth with structural loss from wear, erosion, attrition, abrasion, or abfraction
Covered only for natural teeth

OpenPayer

Clinical Crown Lengthening

Coverage Criteria for Clinical Crown Lengthening

Coding and Radiographic/Timing Standards

Provider Actions, Prior Authorization, and Documentation

Standards and Definitions

Background on Clinical Crown Lengthening