Generally Accepted Indications
A direct restoration is generally considered medically necessary and clinically appropriate when the dental record documents an accepted indication and the restoration is expected to restore and maintain tooth form and function with a good long-term prognosis.
ONE or more of the following generally accepted indications
An active cavitated carious lesion for which a nonrestorative intervention is unlikely to provide a good long-term prognosis for preserving tooth form and function.
Slight to moderate coronal structure loss caused by tooth fracture, a noncarious cervical lesion, attrition, abrasion, or erosion, with enough intact tooth structure remaining for a direct restoration to have a good long-term prognosis.
Slight to moderate coronal structure loss after successful endodontic therapy, with sufficient intact tooth structure remaining for a direct restoration to restore and maintain tooth form and function.
Failure of a direct or indirect restoration when repair with a direct restoration is expected to have a good long-term prognosis.
Additional Clinical and Coding Criteria
Depending on the patient's condition and circumstances, all of the following clinical, diagnostic, treatment, and reporting requirements may apply to coverage determinations.
Applicable clinical and coding requirements
Complete and document a comprehensive evaluation of the teeth and surrounding tissues before planning and performing direct restoration treatment, including identification of noncavitated and cavitated carious lesions.
Address untreated caries or fractures, failed restorations, periodontal disease, endodontic pathology, and structural weakness in the dentition as part of the overall treatment plan.
Perform direct restorations in accordance with applicable standards of dental practice for restorative material selection, preparation, marginal integrity, interproximal contacts, and occlusion.
Report a restoration limited to one tooth surface with the appropriate single-surface procedure code; report a restoration extending without interruption across two or more contiguous surfaces with the appropriate multiple-surface procedure code. Extension across the line angle generally constitutes involvement of a contiguous surface, subject to any program-specific multiple-surface criteria.
Potentially Not Medically Necessary or Clinically Inappropriate
Depending on the clinical circumstances, a direct restoration may be considered not medically necessary, inadvisable, or deficient in clinical quality and may result in disapproval of benefits.
ONE or more of the following concerns may support noncoverage or disapproval
The record lacks pretreatment documentation of an active cavitated carious lesion, tooth fracture, restoration failure, or another accepted indication for placement of a direct restoration.
Appropriate removal of caries has not been performed.
Appropriate removal of an existing restoration has not been performed.
The tooth is affected by unresolved periapical pathology, failed endodontic treatment, an improperly aligned post, or failed root integrity caused by root fracture or a resorptive defect.
The tooth has insufficient alveolar bone support, advanced furcation involvement, or advanced mucogingival defects.
Potentially Noncovered Purposes
Direct restorations performed solely for the following purposes may not be covered. The member's plan documents in effect on the date of service control whether a service is a covered benefit.
ONE or more potentially noncovered purposes
Tooth structure loss resulting from attrition, abrasion, abfraction, or erosion.
Diagnosis or treatment of temporomandibular joint dysfunction.
Correction of congenital or developmental malformations.
Vertical dimension adjustment.
Resin-based composite restorations placed in noncarious pits and fissures contained within a tooth's enamel should be reported as a sealant. Active carious lesions in pits and fissures that do not extend into dentin should be reported with the D1352 preventive resin restoration procedure code. Composite restorations extending into dentin should be reported with the appropriate resin-based composite restoration procedure code.
A direct restoration performed solely to address tooth structure loss from attrition, abrasion, abfraction, or erosion, or solely for periodontal splinting, diagnosis or treatment of temporomandibular joint dysfunction, vertical dimension adjustment, stabilization of occlusion, or a related purpose may not be covered. Coverage depends on the member's dental plan documents in effect on the date of service.
A direct restoration placed solely to improve esthetic appearance may not be medically necessary or covered, including diastema closure, cosmetic restoration of a peg lateral tooth, or replacement of an intact and functional amalgam restoration with a resin-based composite material.
A direct restoration may be clinically inappropriate when the tooth is broken down by dental caries, extensive restoration, and/or fracture and has insufficient sound tooth structure for successful restoration. Related concerns include unresolved endodontic or periapical disease, failed root integrity, inadequate periodontal support, or another condition that prevents a predictable long-term result.
High caries risk and/or poor oral hygiene may present a relative contraindication to restorative treatment and may affect medical-necessity or clinical-appropriateness determinations. The clinician should consider whether disease control and an alternative treatment are more appropriate before placing a direct restoration.