CurrentBlue Cross Blue Shield - WisconsinPolicy 02-901

Core Buildup (includes post and core procedures)

Defines clinical documentation and coverage criteria for core buildup and post-and-core dental procedures for members of the payer; applies to determination of dental/benefit coverage for these services.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyCore Buildup - includes post and core procedures

Policy CodePolicy 02-901

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2023

Next Review Date

Key ActionInclude recent, dated, pretreatment radiographs showing the radiographic apex and supporting clinical documentation to substantiate medical necessity for listed CDT codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6CDT codes listed

16clinical criteria items

01/01/2023publish date

10/21/2022last review

Coverage Criteria

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Posterior coverage: (a) A significant portion of missing tooth structure due to caries, fracture, or defective restoration; (b) Insufficient tooth structure coronal to the intended restorative margin for adequate retention; (c) A crown or retainer is either existing (to be recemented/rebonded) or is treatment planned.all three required

From Criteria items 3a-c

Anterior tooth core buildup coverage

Covered when ALL of the following are met for anterior teeth:

Anterior coverage: (a) A significant portion of missing tooth structure due to caries, fracture, or defective restoration; (b) Insufficient tooth structure coronal to the intended restorative margin for adequate retention; (c) A crown or abutment is either existing or is treatment planned.all three required

From Criteria items 4a-c

Primary tooth coverage

Covered when ALL of the following are met for primary teeth:

Primary tooth coverage: The primary tooth must meet the same criteria as a permanent tooth; radiographic images must demonstrate intact root structure, adequate periodontal support with no evidence of active periodontal disease, occlusal function with an opposing tooth when criteria for full-coverage indirect restoration are met, and radiographs must show no permanent successor present or that the permanent successor is unlikely to erupt.all required

From Criteria item 10

Exclusions and not covered indications

Not covered when ANY of the following apply:

Pulpal protection / preparation fillers: Core buildup submitted for pulp capping, pulpal insulation/protection, undercut block-outs, enhancement of box-form, or as filler to reduce final restorative material is not considered a covered service.any one suffices

From Criteria item 5

Wear-related exclusion: Core buildups placed for repair of complications from attrition, abrasion, erosion, or abfraction are not covered.any one suffices

From Criteria item 8

Partial coverage exclusion: Core buildups will not be considered for partial-coverage indirect restorations (e.g., onlays, inlays, veneers, or 3/4 crowns).any one suffices

From Criteria item 9

Developmental defect exclusion: Core buildups performed for correction of developmental or congenital defects are not covered.any one suffices

From Criteria item 18

Subgingival caries exclusion: Benefits will not be considered when subgingival/subosseous caries may potentially compromise supracrestal tissue attachment without addressing restorative and periodontal considerations.any one suffices

From Criteria item 16

Structural assessment

Coverage contingent on clinical judgment considering multiple factors:

Crown-to-root ratio: Unfavorable crown-to-root ratios poorer than 1:1 require a comprehensive assessment of the patient's full‑mouth dental condition, medical and dental history, periodontal history and continuing care, age, and occlusion before core buildup is considered.assessment required

From Criteria item 15

Periodontal status: Teeth with uncontrolled or untreated periodontal disease evidenced by loss of supporting bone will not be considered for core buildup placement and require periodontal evaluation and management.assessment required

From Criteria item 11

Endodontic status: Teeth with untreated or unresolved periapical or periradicular pathology, unresolved lesion near the pulp without treatment planned, overfill/underfill root canal obturation, poor condensation, or internal/external resorption may not be considered for benefit; endodontic status must be reviewed per Dental Policy 03-001.assessment required

From Criteria item 17a-d

Core buildups are not covered when submitted for purposes other than providing retention for a full‑coverage indirect restoration. Specifically, core buildup will not be considered when billed for pulp capping, pulpal insulation or protection, undercut block‑outs, enhancement of box‑form, or as fillers to reduce final restorative material. The policy also excludes core buildups intended solely to correct developmental or congenital defects and those placed to repair wear‑related complications such as attrition, abrasion, erosion, or abfraction.

Endodontic therapy alone does not automatically justify a core buildup or post and core. For anterior teeth in particular, a core buildup is covered only when there is a significant portion of missing tooth structure, insufficient coronal tooth structure for retention, and a crown or abutment existing or treatment planned. Additionally, teeth with unresolved endodontic issues — including untreated periapical/periradicular pathology, unresolved lesions near the pulp without a planned endodontic treatment, overfill/underfill or poor root canal obturation, or internal/external resorption — will not be considered for benefit and should be managed according to Dental Policy 03‑001 (Endodontic Therapy).

Provider Actions & Documentation

Prior Authorization

Prior Authorization / Documentation Expectation

Prior authorization and documentation are required for the listed CDT codes and associated procedures. Submit pretreatment diagnostic radiographs that include the radiographic apex and patient identifiers. Prior authorization may be required per group contract — verify member benefits and obtain authorization when indicated.

Affected codes: D2950, D2952, D2953, D2954, D2957, D2955

Documentation Required

Required Baseline Documentation

Must include most recent, dated, properly identified pretreatment diagnostic radiographic image(s) that include the radiographic apex. Clinical chart notes, intra-oral photographs, current dated 6‑point periodontal charting, and history of periodontal therapy may also be required to substantiate medical necessity.

Required baseline: pretreatment radiographic image(s) including radiographic apex and patient identifiers
Clinical chart notes documenting rationale and findings
Intra-oral photographs when applicable
6‑point periodontal charting and periodontal therapy history when indicated

Billing Rule

Contract-Dependent Alternation to Simpler Restoration

Per group contract terms, a core buildup may be alternated to a simpler one‑surface restoration in certain situations (for example, when root canal therapy is performed through a retained existing crown). Verify contract-specific alternation rules prior to billing or obtaining authorization.

Contract-dependent alternation: may allow alternation to a one‑surface restoration when RCT is performed through a retained existing crown
Check member/group contract for allowed alternations and prior authorization requirements

Background

A core buildup is the restoration of coronal tooth structure to provide sufficient retention for an indirect full‑coverage restoration when remaining tooth structure is inadequate due to caries, fracture, or a defective restoration. Its purpose is to reestablish form and retention so a crown or retainer can be successfully placed or rebonded; it is not intended for pulpal protection, as a filler for preparation irregularities, or to substitute for appropriate periodontal or endodontic treatment.

Definitions

Core buildup — definition

DefinitionRestoration of coronal tooth structure to provide retention for an indirect full-coverage restoration when insufficient remaining tooth structure or retention exists; not intended for pulpal insulation, filler to eliminate undercuts/box form, or correction of preparation irregularities.

Intended purposeProvides retention for an indirect full-coverage restoration (e.g., crown) when inadequate coronal tooth structure remains due to caries, fracture, or defective restoration.

Not indicated forPulpal insulation/protection, elimination of undercuts or box-form irregularities, or filling concave irregularities in a tooth preparation.

Coverage considerationDetermination of medical/dental necessity requires documentation and must meet contract-specific benefit requirements; necessity does not guarantee coverage under the dental plan.

Occlusal function for third molar crowns — requirement

Occlusal function requirementFor third molar crowns, the completed crown must be in occlusal function and must occlude with at least one-third of an opposing tooth.

ExceptionsExceptions may be considered for crowns that support removable or fixed partial dentures; applicability may be group contract dependent.

Assessment implicationThird molars not meeting occlusal function criteria are at risk for denial unless documented justification or contract exceptions apply.