CurrentEmpire BluecrossPolicy 02-902

Veneers_Guideline_02-902

Policy governing clinical review and medical/dental necessity criteria for placement of labial veneers (resin and porcelain) under the plan; describes qualifying clinical indications, documentation requirements, exclusions (cosmetic and developmental), and applicable CDT procedure codes (informational).

Policy Summary

PayerEmpire Bluecross

PolicyVeneers_Guideline_02-902

Policy CodePolicy 02-902

Change TypeClarified (administrative update)

Effective Date01/01/2024

Next Review Date

Key ActionObtain and retain a current (within 12 months) pretreatment periapical radiograph showing the apex to evaluate lack of pulpal and/or periapical pathosis; provide upon request.

SourceLink

POLICY UPDATE CHANGES

Document updated with Clinical Policy publish date 01/01/2024 and last review date 08/23/2023.

3Primary CDT codes listed

MultipleExclusions (cosmetic/developmental/size discrepancy)

1Required radiograph within past year

Coverage Summary

Scope: Policy governing clinical review and medical/dental necessity criteria for placement of labial veneers (resin and porcelain); describes qualifying clinical indications, documentation requirements, exclusions (cosmetic and developmental), and applicable CDT procedure codes (informational).

Criteria for Veneer Restorations (to qualify)

To qualify for veneer restorations, all of the following criteria must be met:

ALL of the following

Placement of veneers must be necessary, appropriate and meet generally accepted standards of care
Must have a reasonable expectation for success
A current (within 12 months), pretreatment periapical radiographic image showing the apex is required for evaluation of lack of pulpal and/or periapical pathosisperiapical radiograph within 12 months
Radiograph required for evaluation
Must have fully intact lingual surfaces on anterior teeth that can support veneer placement when there are large areas of decay; when areas of decay are considered too large, a full crown may be the more appropriate restoration
Assess structural support; consider crown if decay extensive
The periodontal health and long term prognosis of the teeth must be considered; placement on teeth with uncontrolled or untreated periodontal disease is not appropriate
Documentation relative to history of definitive periodontal treatment is required
To be considered for a labial veneer
- Tooth must demonstrate significant loss of tooth structure and/or involvement of one or both incisal angles or cusp tip of a canine
  Documentation must be provided upon request
- Upon request the degree of tooth breakdown must be documented by report, clinical chart notes, and photographically
  Documentation must be provided upon request
Benefits for replacement of defective veneers (e.g., veneers that have become defective after initial placement because of normal wear, fracture or caries) are based on contractual frequency limitations
Not considered appropriate reasons for placement of veneers
- For cosmetic purposes
- For correction of congenital/developmental problems
- For correction of tooth size discrepancies
Restorative procedures for repair of complications from wear, attrition, abrasion, erosion, and abfraction do not meet contractual criteria for treatment
Veneers are not appropriate restorations for patients who demonstrate severe bruxism or grinding as this condition places undue stress on the restoration compromising long term prognosis
Severe bruxism places undue stress and compromises long term prognosis

Provider Actions & Documentation Requirements

Documentation Required

Radiographic documentation required

Obtain and retain a current (within 12 months) pretreatment periapical radiograph showing the apex to evaluate lack of pulpal and/or periapical pathosis; provide upon request.

Periapical radiograph recency: within 12 months

Documentation Required

Supportive documentation for tooth breakdown

Document degree of tooth breakdown with report, clinical chart notes, and photographs upon request.

Documentation Required

Periodontal treatment history required

Document history of definitive periodontal treatment and demonstrate controlled periodontal health prior to veneer placement; veneers on teeth with uncontrolled/untreated periodontal disease are not appropriate.

Billing Rule

Replacement veneers subject to contract frequency limits

Coverage for replacement of defective veneers is determined based on contractual frequency limitations; verify member contract for applicable frequency restrictions.

D2960
D2961
D2962

Background & Evidence

Background: Veneers are described as a conservative method that restores function and is appropriate when teeth have been damaged by an injury causing significant loss of tooth structure, rather than minor loss of an incisal edge/angle that can be restored by other means. The plan performs review of dental veneers to ensure services meet contractual requirements and generally accepted standards of dental care.

Definition — Generally accepted standards of dental practice: Standards based on credible scientific evidence published in peer-reviewed dental literature, specialty society recommendations, the views of recognized dentists in the clinical area, and other credible sources.

Evidence summary: References cited include a literature review on porcelain veneers, the American Academy of Pediatric Dentistry guideline on pediatric restorative dentistry, a study on E-max porcelain laminate veneer efficacy over 2 years, and the CDT 2024 Current Dental Terminology listing relevant procedure codes.

Key Definitions & Thresholds

Render thresholds and definitions

Periapical radiograph recencywithin 12 months

Definition termGenerally accepted standards of dental practice

DefinitionStandards based on credible scientific evidence published in peer-reviewed dental literature, specialty society recommendations, views of recognized dentists in the clinical area, and other credible sources.

Requirement contextA current (within 12 months), pretreatment periapical radiographic image showing the apex is required for evaluation of lack of pulpal and/or periapical pathosis.

Policy purpose notePlan reviews veneers to ensure services meet generally accepted standards of dental care and contractual requirements; medical necessity determination does not guarantee benefit coverage under the member contract.

Policy Summary

PayerEmpire Bluecross

PolicyVeneers_Guideline_02-902

Policy CodePolicy 02-902

Change TypeClarified (administrative update)

Effective Date01/01/2024

Next Review Date

Key ActionObtain and retain a current (within 12 months) pretreatment periapical radiograph showing the apex to evaluate lack of pulpal and/or periapical pathosis; provide upon request.

SourceLink

On This Page

OpenPayer

Veneers_Guideline_02-902

Coverage Summary

Criteria for Veneer Restorations (to qualify)

Relevant Codes (informational)

Provider Actions & Documentation Requirements

Background & Evidence

Key Definitions & Thresholds

Revision History

D2960	Labial veneer (resin laminate) - direct
D2961	Labial veneer (resin laminate) - indirect
D2962	Labial veneer (porcelain laminate) - indirect