CurrentDelta Dental of OhioPolicy 282.17.v2

Clinical Criteria for Prefabricated Crowns

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Establishes clinical criteria for determining the medical necessity and clinical appropriateness of prefabricated crown placement when a member's dental plan requires utilization review; it does not itself guarantee plan benefit coverage.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Prefabricated Crowns

Policy CodePolicy 282.17.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionSubmit preoperative radiographs and supporting clinical information when authorization is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7Applicable CDT procedure codes listed

9Generally accepted indications

10Conditions that may support disapproval

Most casesPrior authorization requirement

5 years

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CurrentDelta Dental of OhioPolicy 282.17.v2

Clinical Criteria for Prefabricated Crowns

Customize your policy alerts

Sign up for deltadentalofohio Policy 282.17.v2 alerts

Get alerted when Policy 282.17.v2 changes without checking for updates manually.

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Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Prefabricated Crowns

Policy CodePolicy 282.17.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionSubmit preoperative radiographs and supporting clinical information when authorization is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7Applicable CDT procedure codes listed

9Generally accepted indications

10Conditions that may support disapproval

Most casesPrior authorization requirement

5 years

Expected stainless steel crown duration

50%Minimum permanent-tooth bone support

Clinical Coverage Criteria

Generally Accepted Indications

At least one generally accepted indication must be documented in the patient's dental record for a prefabricated crown to be considered for benefit payment.

At least ONE indication

Extensive carious lesions or traumatic damage involving multiple tooth surfaces.
Extensive decalcified cervical surfaces.
A direct restoration is likely to fail because of extensive restoration needs.
Following pulpotomy, pulpectomy, or other endodontic treatment.
Required to retain a space maintainer.
Extensive wear affecting occlusal stability and/or proper mastication.
A developmental defect such as amelogenesis imperfecta, dentinogenesis imperfecta, or enamel hypoplasia.
A diagnosis of high caries susceptibility and/or a history of extensive dental treatment, including multiple restorations, endodontic procedures, and/or extractions.
Physical, mental, or psychosocial problems complicate patient health and treatment, requiring extensive restoration of teeth under general anesthesia.

Stainless Steel Crown — General Criteria

Stainless steel crown criteria are generally met when ALL applicable general conditions below are satisfied.

ALL of the following

The tooth needs a multi-surface restoration and amalgam or other restorative materials have a poor prognosis.
Applicable tooth destruction criterion
- Permanent molar: pathologic destruction from caries or trauma involves four or more surfaces and two or more cusps.
- Permanent bicuspid: pathologic destruction from caries or trauma involves three or more surfaces and at least one cusp.
- Permanent anterior tooth: pathologic destruction from caries or trauma involves four or more surfaces and at least 50% of the incisal edge.

A prefabricated crown used as a definitive restoration for a permanent tooth is subject to review.

A prefabricated crown is inadvisable, unnecessary, or deficient in clinical quality when placed on a tooth that is broken down by dental caries, extensive restoration, and/or fracture with insufficient sound tooth structure for successful restoration.

A prefabricated crown is inadvisable, unnecessary, or deficient in clinical quality when the crown is inadequately prepared or adapted, including a crown with marginal defects and/or inadequate interproximal contacts or occlusion.

A prefabricated crown is inadvisable, unnecessary, or deficient in clinical quality when the patient has an allergy to a material in the restoration, such as nickel.

Stainless steel crown authorization and treatment do not meet criteria when the tooth has subosseous and/or furcation caries, has advanced periodontal disease, is a primary tooth with exfoliation imminent, or crowns are being planned to alter vertical dimension.

A prefabricated crown is inadvisable, unnecessary, or deficient in clinical quality when an alternative treatment is more appropriate for the patient's condition or circumstance based on accepted standards of care.

A prefabricated crown is inadvisable, unnecessary, or deficient in clinical quality when the tooth has unresolved periapical pathology, failed endodontic treatment, an improperly aligned post, and/or failed root integrity due to root fracture or resorptive defect; when the tooth has insufficient alveolar bone support, advanced furcation involvement, and/or advanced mucogingival defects; when a primary tooth is undergoing natural exfoliation; when there is a high caries risk and/or poor oral hygiene presenting a relative contraindication to restorative treatment; or when the patient has a compromised temporomandibular joint likely to cause complications during or after restorative treatment.

Applicable Codes and Clinical Coding Rules

Applicable Dental Procedure Codesmixed

D2928	Prefabricated porcelain/ceramic crown - permanent tooth
D2929	Prefabricated porcelain/ceramic crown - primary 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 - permanent tooth

D2930 code-specific criteriamixedCovered

D2930

Prefabricated stainless steel crown -primary tooth

D2931 code-specific criteriamixedCovered

D2931

Prefabricated stainless steel crown -permanent tooth

D2933 code-specific criteriamixedCovered

D2933

Prefabricated open-face stainless steel crowns (or stainless steel crowns with resin window)

D2934 code-specific criteriamixedCovered

D2934

Prefabricated esthetic coated stainless steel crown - primary tooth

Permanent molar destruction

Surface involvementFour or more surfaces affected by caries or trauma

Cusp involvementTwo or more cusps affected by caries or trauma

Tooth typePermanent molar

Permanent bicuspid destruction

Surface involvementThree or more surfaces affected by caries or trauma

Cusp involvementAt least one cusp affected by caries or trauma

Authorization and Documentation Requirements

Prior Authorization

Check the plan’s authorization requirements

Prior authorization is generally not required. Where the member’s plan requires authorization for a primary or permanent tooth, submit the required radiographs and supporting clinical information for review.

Prior Authorization

Document completed endodontic treatment

For authorization of a permanent-tooth crown following root canal therapy, include a dated post-endodontic radiograph. The canal must be filled sufficiently close to the radiological apex to provide an apical seal, unless curvature or calcification limits filling to the apex; the filling must be properly condensed or obturated without excessive material beyond the apex.

Documentation Required

Background

Prefabricated crowns are full-coverage restorations adapted to individual teeth. They may be made from stainless steel, esthetically faced stainless steel, resin, porcelain, or ceramic. They are commonly used for primary teeth with extensive caries or trauma, particularly in children at high caries risk, and may provide provisional protection for extensively damaged permanent teeth until a definitive indirect restoration is placed.

Definition

Prefabricated crown

DefinitionA full-coverage restoration adapted to an individual tooth

MaterialsStainless steel, stainless steel with an esthetic resin facing, resin, porcelain, or ceramic substrate

Typical useRestoration of primary teeth with extensive damage from caries and/or trauma

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Prefabricated Crowns

Policy CodePolicy 282.17.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionSubmit preoperative radiographs and supporting clinical information when authorization is required.

SourceLink

On This Page

Primary molar: pathologic destruction from caries or trauma involves two or more surfaces, or substantial occlusal decay has resulted in an enamel shell.

The crown is opposed by a tooth or denture in the opposite arch, or the tooth is an abutment for a partial denture.

The patient is free from active and advanced periodontal disease.

A permanent tooth is at least 50% supported in bone.

This condition applies to permanent teeth.

For permanent teeth, the stainless steel crown is expected to last five years.

This is an expected durability consideration for permanent-tooth stainless steel crowns.

Tooth typePermanent bicuspid

Permanent anterior tooth destruction

Surface involvementFour or more surfaces affected by caries or trauma

Incisal-edge involvementAt least 50% of the incisal edge affected by caries or trauma

Tooth typePermanent anterior tooth

Primary molar destruction

Surface involvementTwo or more surfaces affected by caries or trauma

Alternative thresholdSubstantial occlusal decay resulting in an enamel shell

Tooth typePrimary molar

Permanent tooth bone support

Minimum bone supportAt least 50% supported in bone

ApplicabilityPermanent tooth receiving a stainless steel crown

Periodontal requirementPatient must be free from active and advanced periodontal disease

Permanent stainless steel crown longevity

Expected durationFive years

ApplicabilityStainless steel crowns on permanent teeth

Clinical contextApplies to expected crown longevity under the stated criteria

Submit complete clinical support

Submit preoperative radiographs demonstrating caries or fracture and showing that periodontal, endodontic, and structural conditions support crown placement and maintenance. Radiographs must allow evaluation of the entire tooth from crown to root tip; include the preoperative clinical rationale and, when appropriate, a narrative supporting treatment under sedation or general anesthesia.

Provide intraoral photographs when the need for a preformed crown is not clearly evident radiographically.
Additional relevant clinical information may be requested for coverage decisions.

Documentation Required

Include required imaging with authorization or claims

When authorization is required for a primary or permanent tooth, submit bitewing, periapical, or panoramic radiographs clearly showing the adjacent and opposing teeth. For emergency treatment when authorization was not possible, submit the radiographs with the claim for payment review; if radiographs are unavailable, submit a narrative demonstrating medical necessity.

Denial Risk

Address conditions that may support disapproval

Benefits may be disapproved when the record does not support a generally accepted indication or when the crown is clinically inadvisable, unnecessary, or deficient in quality. Review the tooth and treatment plan for conditions including insufficient sound structure, unresolved periapical pathology or failed endodontic treatment, inadequate bone or periodontal support, natural exfoliation of a primary tooth, inadequate crown adaptation, material allergy, poor oral hygiene or high caries risk, compromised temporomandibular joint, or a more appropriate alternative treatment.

Denial Risk

Screen for stainless steel crown exclusions

Stainless steel crown authorization and treatment do not meet criteria when a lesser restoration is possible, the tooth has subosseous or furcation caries, the tooth has advanced periodontal disease, a primary tooth is nearing exfoliation, or the crown is planned to alter vertical dimension.