CurrentDelta Dental of OhioPolicy 282.16.v2

Clinical Criteria for Restorative Substructures

Customize your policy alerts

Sign up for deltadentalofohio Policy 282.16.v2 alerts

Get alerted when Policy 282.16.v2 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Clinical criteria, documentation requirements, and utilization-management rules for core buildups, posts and cores, and related restorative substructures used with crowns or fixed partial denture retainer crowns.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Restorative Substructures

Policy CodePolicy 282.16.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateNot specified

Key ActionSubmit prior authorization with the required periapical and panoramic or full-mouth radiographic documentation for D2952 or D2954.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50% or moreMissing coronal structure for qualifying core buildup

Once per toothD2950 frequency limit

3 pinsMaximum D2951 pins per tooth

2 componentsRequired imaging components for D2952 or D2954 authorization

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentDelta Dental of OhioPolicy 282.16.v2

Clinical Criteria for Restorative Substructures

Customize your policy alerts

Sign up for deltadentalofohio Policy 282.16.v2 alerts

Get alerted when Policy 282.16.v2 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Restorative Substructures

Policy CodePolicy 282.16.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateNot specified

Key ActionSubmit prior authorization with the required periapical and panoramic or full-mouth radiographic documentation for D2952 or D2954.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50% or moreMissing coronal structure for qualifying core buildup

Once per toothD2950 frequency limit

3 pinsMaximum D2951 pins per tooth

2 componentsRequired imaging components for D2952 or D2954 authorization

Eligible D2952 and D2954 tooth locations

Clinical Coverage Criteria

Core Buildup Substructure

Core buildup substructure is generally indicated when the following condition is met:

Core buildup indication: A preoperative assessment shows that 50 percent or more of the original coronal tooth structure is missing due to caries or fracture, resulting in insufficient retention for a crown.50 percent or more of original coronal structure missing

Insufficient retention exists when a crown preparation alone cannot create adequate opposing vertical walls to resist displacement under occlusal forces.

Post and Core Substructure

Post and core substructure is generally indicated when ALL of the following are met:

Post and core indications

Endodontic treatment: The tooth has successfully completed endodontic therapy.Completed and successful
Crown need: The tooth needs a crown to protect the remaining tooth structure or support a fixed partial denture.Crown indicated
Core need: Missing tooth structure requires a core buildup.Required
Post need: A post is required to retain the core material.Required
Root length: The tooth has sufficient root length to accommodate the post.Sufficient root length

Not Medically Necessary, Inadvisable, or Clinically Deficient

A restorative substructure may be determined not medically necessary, inadvisable, or clinically deficient under any of the following conditions:

Nonqualifying or unfavorable clinical circumstances

The tooth has sufficient original coronal structure to provide adequate strength and retention for a crown without a restorative substructure.
The restorative substructure is not performed in conjunction with a crown, including when it is performed as a definitive amalgam or resin-based composite restoration or submitted with an inlay, onlay, veneer, or three-quarter crown.
The evidence shows that only a restorative foundation filler was placed to eliminate an undercut, box form, or concave irregularity in a crown preparation.
The tooth is broken down by dental caries, extensive restoration, or fracture and lacks sufficient sound tooth structure for successful restoration.

D2950 Core Buildup Requirements

D2950 coverage is subject to ALL of the following requirements:

D2950 service limitations

The service is provided on a permanent tooth.
The service is provided in preparation for or in conjunction with an adult crown procedure.
No more than one core buildup is submitted for the tooth on the date of service.

D2952 and D2954 Post-and-Core Authorization

D2952 and D2954 authorization criteria require ALL of the following:

Cast or prefabricated post and core authorization criteria

Tooth location and dentition: The tooth is a properly endodontically treated permanent anterior tooth in one of the specified ranges: 6-11 or 22-27.Permanent anterior teeth 6-11 and 22-27
Endodontic status: The tooth is properly filled after completion of root canal therapy.Properly treated and filled
Crown support: The tooth does not have sufficient tooth structure to support a crown.Insufficient tooth structure

Restorative substructures are not qualifying crown-associated services when performed as definitive amalgam or resin-based composite restorations, or when submitted with an inlay, onlay, veneer, or three-quarter crown.

A restorative substructure placed on a primary tooth undergoing natural exfoliation is an excluded circumstance.

Additional concerns include insufficient sound tooth structure for successful restoration; unresolved periapical pathology, failed endodontic treatment, an improperly aligned post, root fracture, or a resorptive defect; inadequate alveolar bone support, advanced furcation involvement, or advanced mucogingival defects; insufficient healing after crown lengthening; or an inadequately prepared or adapted substructure. An allergy to a restorative material, high caries risk or poor oral hygiene, a compromised temporomandibular joint likely to cause complications, or a more appropriate alternative treatment may also support a determination that the procedure is not medically necessary or clinically appropriate.

Procedure Codes and Billing Limits

Applicable Dental Procedure Codesmixed

D2950	core buildup, including any pins when required
D2952	post and core in addition to crown, indirectly fabricated
D2953	each additional indirectly fabricated post - same tooth
D2954	prefabricated post and core in addition to crown
D2957	each additional prefabricated post - same tooth
D2955	post removal

Appendix A - D2950 Core buildupmixed

D2950

Core buildup, including any pins when required

Appendix A - D2951 Pin retentionmixed

D2951

Pin retention (per tooth in addition to restoration)

Appendix A - D2952 Cast post and coremixed

D2952

Cast post and core in addition to crown

Appendix A - D2954 Prefabricated post and coremixed

D2954

Prefabricated post and core in addition to crown

Missing Original Coronal Structure

Required missing structure50 percent or more of the original coronal tooth structure must be missing.

Qualifying causesThe missing structure must be due to caries or fracture.

Clinical consequenceThe loss must result in insufficient retention for a crown.

D2950 Frequency

Procedure codeD2950 — Core buildup, including any pins when required.

Frequency limit

Authorization, Documentation, and Billing Guidance

Prior Authorization

D2952 Cast Post and Core: Prior Authorization

Prior authorization is required before submitting D2952 (cast post and core in addition to crown). Include the clinical and radiographic materials needed to establish medical necessity and assess the involved tooth and supporting tissues.

Submit a periapical radiograph and either a panoramic film or a full-mouth series of X-rays for the involved tooth or teeth.
Include documentation that the tooth is a properly endodontically treated permanent anterior tooth, lacks sufficient tooth structure to support a crown, and is properly filled after root canal therapy.
Document the overall health and positive long-term prognosis of the remaining teeth and gums, including the absence of significant risk factors for worsening disease or continued oral breakdown.

Prior Authorization

D2954 Prefabricated Post and Core: Prior Authorization

Prior authorization is required before submitting D2954 (prefabricated post and core in addition to crown). Include the clinical and radiographic materials needed to establish medical necessity and assess the involved tooth and supporting tissues.

Policy Background

Restorative substructures rebuild missing coronal tooth structure so a full-coverage crown can obtain adequate strength, retention, and resistance to displacement during occlusal function. A core buildup restores the coronal structure directly. A post and core builds restorative material around a post in a successfully endodontically treated tooth when the tooth’s anatomy alone cannot retain the core.

Key Definitions

Core Buildup Restorative Substructure

PurposeA core buildup restores missing coronal tooth structure.

Restorative materialThe material must have the strength and retentive characteristics to maintain a full-coverage crown against displacement under occlusal function.

Retention assistanceOne or more retentive pins may be placed when required by the preoperative condition of the tooth's original coronal structure.

Post and Core Restorative Substructure

ProcedureA post and core builds restorative core material around a post secured in the root of a tooth.

Endodontic requirementThe tooth must have undergone complete and successful endodontic treatment.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Restorative Substructures

Policy CodePolicy 282.16.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateNot specified

Key ActionSubmit prior authorization with the required periapical and panoramic or full-mouth radiographic documentation for D2952 or D2954.

SourceLink

On This Page

The tooth has unresolved periapical pathology, failed endodontic treatment, an improperly aligned post, or failed root integrity due to root fracture or resorptive defect.

The tooth has insufficient alveolar bone support, advanced furcation involvement, or advanced mucogingival defects.

The substructure is placed on a primary tooth undergoing natural exfoliation.

Adequate healing time has not been allowed following crown lengthening.

The restorative substructure is inadequately prepared or adapted.

The patient has an allergy to a material in the restoration, such as nickel.

The patient has high caries risk or poor oral hygiene that presents a relative contraindication to restorative treatment.

The patient has a compromised temporomandibular joint likely to cause complications during or after restorative treatment.

An alternative treatment is more appropriate for the patient's condition or circumstance based on accepted standards of care.

Required imaging: The request includes a periapical radiograph and either a panoramic film or a full-mouth series of X-rays of the involved tooth or teeth.Periapical plus panoramic film or full-mouth series

Long-term prognosis: The overall health of the remaining teeth and gums has a positive long-term prognosis and is free of significant risk factors leading to worsening disease or continuing breakdown of the oral condition.Positive long-term prognosis

Core buildup is limited to once per tooth per date of service.

Crown-related useThe service must be provided in preparation for or in conjunction with an adult crown procedure.

D2951 Pin Quantity

Procedure codeD2951 — Pin retention, per tooth in addition to restoration.

Maximum quantityA maximum of three pins per tooth will be reimbursed.

Quantity basisThe limit applies per tooth.

Eligible Anterior Tooth Locations

Applicable proceduresThe location limit applies to D2952 cast post and core and D2954 prefabricated post and core.

Eligible dentitionThe tooth must be a permanent anterior tooth.

Eligible tooth numbersEligible tooth ranges are 6-11 and 22-27.

Submit a periapical radiograph and either a panoramic film or a full-mouth series of X-rays for the involved tooth or teeth.
Include documentation that the tooth is a properly endodontically treated permanent anterior tooth, lacks sufficient tooth structure to support a crown, and is properly filled after root canal therapy.
Document the overall health and positive long-term prognosis of the remaining teeth and gums, including the absence of significant risk factors for worsening disease or continued oral breakdown.

Documentation Required

Preoperative Radiographic Evidence

Submit preoperative radiographic evidence demonstrating that 50% or more of the tooth’s original coronal structure is missing because of caries or fracture and that the periodontal, endodontic, and structural condition can support placement and maintenance of the restorative substructure and crown.

Radiographs must permit evaluation of the entire tooth from crown to root tip.
If the need for a restorative substructure is not clear on radiographs, submit an intraoral photograph showing the degree of breakdown.

Documentation Required

Preoperative Clinical Rationale

Document the preoperative clinical rationale for performing the restorative substructure and crown. The treatment decision should be supported by a thorough clinical and radiographic examination and an appropriate treatment plan.

Submit the relevant clinical documentation from the patient’s dental record with the claim when medical necessity or clinical appropriateness is reviewed.
Delta Dental of Ohio may request additional clinical information relevant to the patient’s care.

Documentation Required

Post-and-Core Imaging Requirements

For each D2952 or D2954 authorization request, submit the required radiographic combination to evaluate the involved tooth or teeth and the overall health of the teeth and gums.

One periapical radiograph is required.
Also submit either a panoramic film or a full-mouth series of X-rays.

Denial Risk

Foundation Filler or Unnecessary Substructure

Do not bill a restorative foundation filler as a core buildup. Payment may be disapproved when the original coronal structure is sufficiently intact to retain a crown and the procedure only eliminates an undercut, box form, or concave irregularity; payment may also be disapproved when the substructure is not performed in conjunction with a crown.

A core buildup restores missing coronal structure with material strong and retentive enough to maintain a full-coverage crown under occlusal function.
Restorative substructures submitted as definitive amalgam or resin-based composite restorations, or with an inlay, onlay, veneer, or three-quarter crown, are not eligible under these criteria.

Denial Risk

Poor Tooth, Endodontic, Periodontal, or Structural Prognosis

A restorative substructure may be denied when the tooth or supporting tissues have a poor prognosis or unresolved disease that threatens successful restoration.

Insufficient sound tooth structure because of extensive caries, restoration, or fracture.
Unresolved periapical pathology, failed endodontic treatment, improperly aligned post, root fracture, or resorptive defect.
Insufficient alveolar bone support, advanced furcation involvement, or advanced mucogingival defects.
Primary tooth undergoing natural exfoliation or inadequate healing time following crown lengthening.
The remaining teeth and gums must have a positive long-term prognosis and be free of significant risk factors for worsening disease or continued oral breakdown.

Denial Risk

Clinical Contraindications or Alternative Treatment

Review contraindications and alternatives before treatment. Coverage may be denied for an inadequately prepared or adapted substructure, a material allergy, elevated caries risk or poor oral hygiene, a compromised temporomandibular joint likely to cause complications, or when another treatment is more appropriate under accepted standards of care.

Assess and document material allergies, including allergies such as nickel.
Consider high caries risk and poor oral hygiene as relative contraindications to restorative treatment.
Do not proceed without adequate preparation and adaptation of the restorative substructure.
Evaluate whether an alternative treatment better fits the patient’s condition or circumstances.

Billing Rule

D2950 Tooth and Crown Limitations

D2950 (core buildup, including pins when required) is covered only for a permanent tooth and must be provided in preparation for or in conjunction with an adult crown procedure.

Do not use D2950 for primary teeth.
The service is not eligible when performed as a standalone definitive restoration or with an inlay, onlay, veneer, or three-quarter crown.
The tooth must have sufficient remaining clinical circumstances to support the planned crown after the buildup.

Billing Rule

Post-and-Core Eligibility Limits

Apply the eligibility limits for post-and-core procedures before requesting authorization. D2952 and D2954 are authorized only for properly endodontically treated permanent anterior teeth that lack sufficient tooth structure to support a crown.

Eligible anterior tooth locations are 6–11 and 22–27.
The tooth should be properly filled after completion of root canal therapy.
The procedure is provided in addition to a crown and is not indicated when anatomic features alone provide sufficient retention for the core or crown.

Unsupported block type: billing_rule；

When usedIt is used when a core is required for crown retention and anatomic features alone are insufficient to retain the core material.

Restorative Foundation Filler

DefinitionA restorative foundation filler is restorative foundation material placed when sufficient original coronal tooth structure remains to retain a crown after crown preparation.

Qualifying useIt is used primarily to eliminate undercuts and other irregularities.

Preparation objectiveThe filler creates a more ideal crown preparation form.

Insufficient Retention

DefinitionInsufficient retention exists when enough original tooth structure has been lost that a crown preparation by itself cannot create opposing vertical walls.

Displacement resistanceThe opposing vertical walls create the retention form that resists displacement of the crown under occlusal forces.

Role of a coreProper placement of core material can provide adequate vertical wall length to support crown retention when the tooth is otherwise suitable for a crown.