CurrentDelta Dental of OhioPolicy 282.22.v2

Clinical Criteria for Single Crown Restorations

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Clinical and documentation criteria for determining whether single crown restorations are medically necessary and clinically appropriate for Delta Dental of Ohio members when utilization management review is required.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Single Crown Restorations

Policy CodePolicy 282.22.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit radiographs clearly showing the involved, adjacent, and opposing teeth before crown treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18Applicable dental procedure codes

50%+Coronal or incisal structure-loss threshold

Prior authorizationAuthorization requirement

5 yearsMinimum expected cast-crown duration

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CurrentDelta Dental of OhioPolicy 282.22.v2

Clinical Criteria for Single Crown Restorations

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Sign up for deltadentalofohio Policy 282.22.v2 alerts

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Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Single Crown Restorations

Policy CodePolicy 282.22.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit radiographs clearly showing the involved, adjacent, and opposing teeth before crown treatment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18Applicable dental procedure codes

50%+Coronal or incisal structure-loss threshold

Prior authorizationAuthorization requirement

5 yearsMinimum expected cast-crown duration

Specified permanent anterior teeth

Clinical Coverage Criteria

Accepted clinical indications

A single crown may be considered for benefit payment when a generally accepted indication is documented and the tooth has a reasonable restorative prognosis.

At least one accepted indication

Extensive coronal loss from caries, restoration failure, or fracture
- All applicable conditions
  - The tooth has extensive loss of coronal structure due to dental caries, restoration failure, and/or fracture, leaving insufficient intact tooth structure for a direct restoration with a good long-term prognosis50% or more of coronal tooth structure missing
Post-endodontic coronal loss
- The tooth has extensive loss of coronal structure following successful endodontic therapy, leaving insufficient intact tooth structure for a direct restoration with a good long-term prognosis
Fracture plane isolating a cusp
- A documented fracture plane isolates one or more cusps, causes consistent reproducible pain to cold and/or biting pressure, has not compromised the pulp or root, and is expected to improve with cuspal reinforcement from a crown
Abnormal enamel or dentin formation
- Abnormal enamel and/or dentin formation requires crown coverage to maintain the tooth's proper structure and function
Unserviceable existing crown
- An existing crown is unserviceable because of recurrent dental caries or fracture and requires replacement to maintain the tooth's proper structure and function

General permanent-tooth criteria

The following general treatment and tooth-condition criteria should be met.

All applicable general criteria

Restorative prognosis
- The permanent tooth needs a multisurface restoration and other restorative materials have a poor prognosis
Functional relationship
- The crown is opposed by a tooth or denture in the opposite arch
- The tooth is an abutment for a partial denture
Periodontal status

Post-endodontic crown criteria

For a crown following root canal therapy, all endodontic documentation and technical criteria should be satisfied.

Post-endodontic requirements

The request includes a dated post-endodontic radiograph
Adequate endodontic result
- The canal is filled sufficiently close to the radiological apex to ensure an apical seal
  An exception applies when curvature or calcification limits the ability to fill the canal to the apex.
- The filling is properly condensed or obturated and does not extend excessively beyond the apex

Nonqualifying or disqualifying conditions

The procedure is generally unnecessary, inadvisable, deficient, or not eligible when any applicable disqualifying condition is present.

One or more disqualifying conditions

The existing crown remains intact and functional
The tooth does not have extensive coronal loss and a direct restoration would have a good long-term prognosis
A lesser restoration is possible or an alternative treatment is more appropriate based on accepted standards of care
The crown is planned solely to improve esthetic appearance, including diastema closure or cosmetic restoration of a peg lateral tooth
The tooth has craze lines, surface cracks, anatomic grooves, or sound stained or unstained pits or fissures without a fracture plane isolating a cusp

Retained primary tooth consideration

Retained primary tooth crown requests are evaluated individually.

Case-by-case evaluation

The retained primary tooth and surrounding conditions are evaluated individually
Factors considered
- Structural integrity of the tooth is considered
- The condition of the remaining root is considered
- Periodontal support is considered
- The extent and progression of infraocclusion are considered

Replacement of an existing crown is not eligible when the crown remains intact and functional. Replacement may be considered when recurrent caries or fracture has made the crown unserviceable and replacement is needed to maintain the tooth’s structure and function.

A crown is generally not appropriate when the tooth does not have extensive coronal loss and a direct restoration would have a good long-term prognosis for restoring and protecting tooth contours and function.

Crowns provided solely to improve appearance are not covered. Excluded cosmetic purposes include diastema closure, cosmetic restoration of a peg lateral tooth, appearance improvement, vertical-dimension adjustment, and other cosmetic corrections identified as plan exclusions.

Craze lines, surface cracks, anatomic grooves, and sound stained or unstained pits or fissures do not support crown coverage when there is no documented fracture plane isolating one or more cusps.

A porcelain veneering fracture is not sufficient when it does not compromise crown structure or function. Chipped or fractured porcelain without associated decay is also nonqualifying for crown treatment.

Crown treatment is not appropriate for a tooth with unresolved periapical pathology, failed endodontic treatment, an improperly aligned post, root fracture, or a resorptive defect. Requests may also fail when there is insufficient alveolar support, advanced furcation involvement, or advanced periodontal disease.

Crowns on primary teeth are generally not eligible, including teeth undergoing natural exfoliation. Plan provisions may also exclude crowns for children under a specified age, such as under age 12; the member’s plan documents control benefit coverage. Retained primary teeth are reviewed individually based on structural integrity, root condition, periodontal support, infraocclusion, and root resorption.

Crowns provided solely for tooth-structure loss from attrition, abrasion, abfraction, or erosion are not covered. Other excluded purposes include periodontal splinting, correction of congenital or developmental malformations, vertical-dimension adjustment, stabilization of occlusion, cosmetic improvement, and other plan-excluded treatment purposes.

Crowns provided only for cosmetic reasons will not be reimbursed. For functional anterior crown requests, the clinical record must support a covered functional need rather than cosmetic improvement.

A single crown is not medically necessary or clinically appropriate when a lesser or direct restoration can predictably restore and protect the tooth. Crown treatment is generally reserved for cases in which other restorative materials have a poor long-term prognosis or an alternative treatment is not more appropriate.

A crown is not medically necessary or clinically appropriate for a primary tooth or for a tooth lacking adequate periodontal, endodontic, alveolar, or structural support. Requests may also fail when the tooth is broken down beyond successful restoration, lacks sufficient sound tooth structure, or has advanced periodontal or furcation involvement.

Crowns provided solely for cosmetic purposes, vertical-dimension alteration, occlusal stabilization, periodontal splinting, developmental correction, or noncarious loss from attrition, abrasion, abfraction, or erosion may be considered not medically necessary or excluded under the member’s plan. An alternative treatment plan may be required when it better meets the patient’s overall dental needs.

Procedure Codes and Clinical Thresholds

Applicable Dental Procedure Codesmixed

D2710	crown - resin-based composite (indirect)
D2712	crown - ¾ resin-based composite (indirect)
D2720	crown - resin with high noble metal
D2721	crown - resin with predominantly base metal
D2722	crown - resin with noble metal
D2740	crown - porcelain/ceramic
D2750	crown - porcelain fused to high noble metal
D2751	crown - porcelain fused to predominantly base metal
D2752	crown - porcelain fused to noble metal
D2753	crown - porcelain fused to titanium and titanium alloys

1–10 of 18

1/2

Covered with criteriaHCPCSCovered

D2752

Porcelain fused to noble metal

Extensive coronal or incisal loss

Coronal structure loss50% or more of coronal tooth structure is missing.

Permanent anterior teethPermanent anterior teeth must involve at least 50% of the incisal edge.

Qualifying causesThe pathologic destruction must result from dental caries, restoration failure, fracture, or trauma, as applicable.

Permanent molar destruction

Tooth typePermanent molar.

Cause of destructionPathologic destruction caused by caries or trauma.

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization and Radiographic Support

Prior authorization is required for covered single crown procedures. Submit appropriate radiographs clearly showing the involved, adjacent, and opposing teeth; emergency treatment performed without authorization still requires sufficient radiographic documentation with the claim.

Acceptable imaging includes bitewings, periapicals, or a panorex.
Radiographs must clearly show the adjacent and opposing teeth for authorization review.

Prior Authorization

D2740 Anterior Crown Authorization

Prior authorization is required for D2740 porcelain/ceramic crowns on permanent anterior teeth when provided for a functional need.

Affected teeth: 6–11 and 22–27.
Cosmetic-only crowns are not reimbursable.
Anterior tooth damage must involve four or more surfaces and at least 50% of the incisal edge.

Policy Background

A single crown restoration is an indirectly constructed restoration that covers part or all of a tooth. It is fabricated outside the mouth after the tooth is prepared and then cemented to the tooth. Crowns are primarily used to restore substantial coronal loss from caries, fracture, failed restorations, or post-endodontic structural compromise when a direct restoration has a poor prognosis.

Key Definitions

Single crown restoration

Restoration typeAn indirectly constructed single crown restoration.

Extent of coverageCovers a portion or all of a tooth.

Fabrication and placementThe tooth is prepared, the crown is fabricated outside the mouth, and the crown is then cemented to the tooth.

Extensive loss of coronal structure

Minimum coronal lossAt least 50% of coronal tooth structure is missing.

Remaining structureInsufficient intact tooth structure remains.

Direct restoration prognosis

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Single Crown Restorations

Policy CodePolicy 282.22.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit radiographs clearly showing the involved, adjacent, and opposing teeth before crown treatment.

SourceLink

On This Page

The patient is free from active and advanced periodontal disease

Applicable structural-destruction threshold

A permanent molar has pathologic destruction from caries or trauma involving four or more surfaces and two or more cusps4 or more surfaces and 2 or more cusps
A permanent bicuspid has pathologic destruction from caries or trauma involving three or more surfaces and at least one cusp3 or more surfaces and at least 1 cusp
A permanent anterior tooth has pathologic destruction from caries or trauma involving four or more surfaces and at least 50% of the incisal edge4 or more surfaces and at least 50% of the incisal edge

Porcelain veneering is fractured without compromising crown structure and function, or porcelain is chipped or fractured without decay

The tooth is broken down with insufficient sound tooth structure for successful restoration

The tooth has unresolved periapical pathology, failed endodontic treatment, an improperly aligned post, root fracture, or a resorptive defect

The tooth has insufficient alveolar bone support, subosseous or advanced furcation involvement, advanced mucogingival defects, or inadequate periodontal support

The patient has active or advanced periodontal disease, high caries risk or poor oral hygiene presenting a relative contraindication, or a compromised temporomandibular joint likely to cause complications

Adequate healing time has not been allowed following crown lengthening

The crown is inadequately prepared or adapted, including marginal defects, inadequate interproximal contacts, deficient axial contours, inadequate retention, or occlusal defects

The crown is on a primary tooth undergoing natural exfoliation or otherwise planned for a primary tooth

The crown is planned for attrition, abrasion, abfraction, erosion, periodontal splinting, congenital or developmental correction, vertical-dimension adjustment, occlusal stabilization, or another plan-excluded purpose

The treatment is for an injury covered under another type of health plan

The patient has an allergy to a material in the restoration

Evidence of root resorption is considered

Four or more surfaces.

Cusp involvementTwo or more cusps.

Permanent bicuspid destruction

Tooth typePermanent bicuspid.

Cause of destructionPathologic destruction caused by caries or trauma.

Surface involvementThree or more surfaces.

Cusp involvementAt least one cusp.

Permanent anterior destruction

Tooth typePermanent anterior tooth.

Cause of destructionPathologic destruction caused by caries or trauma.

Surface involvementFour or more surfaces.

Incisal-edge involvementAt least 50% of the incisal edge.

Expected cast crown duration

Restoration typeCast crown.

Applicable teethPermanent teeth.

Minimum expected durationAt least five years.

Specified permanent anterior tooth numbers

Tooth classificationPermanent anterior teeth.

First tooth-number rangeTeeth 6-11.

Second tooth-number rangeTeeth 22-27.

Anterior tooth surface involvement

Tooth classificationPermanent anterior tooth.

Pathologic causeDestruction caused by caries or trauma.

Minimum surfaces involvedFour or more surfaces.

Incisal-edge involvement

Tooth classificationPermanent anterior tooth.

Required destructionPathologic destruction caused by caries or trauma.

Minimum incisal-edge involvementAt least 50 percent of the incisal edge.

Affected permanent anterior teeth

Affected teethPermanent anterior teeth.

First tooth-number rangeTeeth 6-11.

Second tooth-number rangeTeeth 22-27.

Prior Authorization

D2751 Anterior Crown Authorization

Prior authorization is required for D2751 porcelain fused to predominantly base-metal crowns on permanent anterior teeth when provided for a functional need.

Affected teeth: 6–11 and 22–27.
Cosmetic-only crowns are not reimbursable.
Anterior tooth damage must involve four or more surfaces and at least 50% of the incisal edge.

Prior Authorization

D2752 Anterior Crown Authorization

Prior authorization is required for D2752 porcelain fused to noble-metal crowns on permanent anterior teeth when provided for a functional need.

Affected teeth: 6–11 and 22–27.
Cosmetic-only crowns are not reimbursable.
Anterior tooth damage must involve four or more surfaces and at least 50% of the incisal edge.

Unsupported block type: prior_auth informationneeded?

Denial Risk

Use Lesser Restoration When Prognosis Is Favorable

Use a direct restoration or other lesser treatment when it has a good long-term prognosis for restoring and protecting tooth contours and function. Crown criteria generally require extensive structural loss and poor prognosis for lesser restorative materials.

Do not request a crown when a lesser means of restoration is possible.
For permanent teeth, crown criteria generally require multisurface restorations for which other restorative materials have a poor prognosis.

Step Therapy

Consider Crown Repair

Consider repair instead of replacement when restorative material has failed and repair is reasonably expected to return the crown to a serviceable condition for a reasonable duration of function.

Repair is indicated when the failure is limited to restorative material and crown function can be restored.

Unsupported block type: documentation

Unsupported block type: billing_rule

Unsupported block type: documentation

Unsupported block type: denial_risk

A direct restoration would have a poor long-term prognosis for restoring and maintaining tooth contours and function.