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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialEmpire Bluecross Clinical Crown Lengthening Covera…
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    CurrentEmpire BluecrossPolicy 04-206

    Clinical Crown Lengthening

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    Defines clinical indications, general criteria, exclusions, and coding guidance for clinical crown lengthening (CDT D4249) as used in dental benefit review and utilization management by the plan.

    Policy Summary
    PayerEmpire Bluecross
    PolicyClinical Crown Lengthening
    Policy CodePolicy 04-206
    Change TypeRevised (Annual Review)
    Effective Date01/01/2022
    Last ReviewOct 30, 2021
    Next Review Date
    Key ActionSubmit a diagnostic radiograph documenting < 3 mm of sound tooth structure between restorative margin and alveolar crest; if radiograph is inconclusive, provide additional patient records documenting need for treatment.
    SourceLink
    POLICY UPDATE CHANGES

    Policy status indicates 'Revised' with last review date 10/30/2021 and publish/effective date 01/01/2022.

    1Primary Covered Procedure Code
    9

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    Explicit Exclusion / Non-covered Situations Listed
    2Radiographic and Healing Thresholds

    Coverage Summary

    Defines clinical indications, general criteria, exclusions, and coding guidance for clinical crown lengthening (CDT D4249) as used in dental benefit review and utilization management by the plan.

    Clinical crown lengthening is used when there is insufficient tooth structure exposed to retain a restoration. The plan performs review of crown lengthening due to contractual requirements that benefits meet generally accepted standards of dental care; coverage is subject to the member's contract terms.

    Medically/Dentally Necessary Criteria

    Medically/Dentally Necessary Criteria for Clinical Crown Lengthening

    Covered when ALL of the following are met:

    • Periodontal health: Procedure is clinical crown lengthening in a periodontally healthy environment (periodontally healthy tissues).

      Must be performed only in a periodontally healthy environment.

    • Restorative necessity: There is inadequate tooth structure exposed to the oral cavity to retain a dental restoration.

      Clinical justification required.

    • Radiographic documentation: A diagnostic radiograph documents less than three millimeters of sound natural tooth structure between the restorative margin and the alveolar crest.< 3 millimeters

      A radiograph must be submitted.

    • Additional records if needed: When indications are not evident by radiographic examination, additional patient records are provided documenting the need for treatment.

      Plan may request additional records.

    • Crown-root ratio adequacy: Procedure requires removal of hard (osseous) and soft (gingival) tissue and results in alteration of crown-root ratio such that the resulting ratio remains adequate for long-term tooth prognosis.

      If bone removal results in inadequate crown-to-root ratio, benefit is not expected.

    • Healing interval before final restoration: A minimum healing period is allowed prior to final restoration following clinical crown lengthening.>= 6 weeks

      Provider must allow healing before final restoration.

    • Natural teeth only: Clinical crown lengthening is considered only for natural teeth.

      Not for implants or non-natural teeth.

    • Indication for subgingival caries or fracture: Clinical crown lengthening is considered only when subgingival caries or fracture requires removal of soft and hard tissue to enable restoration of a tooth.

      Restorative necessity required.

    Situations Where Clinical Crown Lengthening Is Not Considered / Is Inclusive

    Situations Where Clinical Crown Lengthening Is Not Considered/Is Inclusive

    Not covered or considered when ANY of the following apply:

    • Concurrent periodontal treatment in same quadrant: Procedure performed in conjunction with any procedure that addresses periodontal treatment for unhealthy periodontal tissues within the same quadrant on the same date of service (e.g., gingivectomy, frenectomy, distal wedge reduction, grafting, scaling and root planing).

      Crown lengthening will not be considered when addressing periodontal disease on same date in same quadrant.

    • Congenital or developmental defects (elective): Procedure performed to correct congenital or developmental defects (elective treatment).

      Considered elective and not covered as medical necessity.

    • Cosmetic indications: Procedure performed for cosmetic reasons.

    Coding

    Primary CDT code for clinical crown lengtheningCPT
    D4249Clinical crown lengthening - hard tissue

    Provider Actions / Billing Guidance

    Documentation Required

    Radiograph and supporting records submission

    Submit a diagnostic radiograph documenting < 3 mm of sound tooth structure between the restorative margin and the alveolar crest; if radiograph is inconclusive, provide additional patient records documenting need for treatment.

    • D4249
    Denial Risk

    Exclusions that may lead to non-coverage

    Claims may be denied if procedure is for cosmetic reasons, to correct congenital/developmental defects, for structural loss from wear/erosion/attrition/abrasion/abfraction, or performed in a periodontally unhealthy quadrant on same date of service.

    • D4249
    • D4274

    Background & Evidence

    Clinical crown lengthening is appropriate in a periodontally healthy environment when there is inadequate tooth structure exposed to the oral cavity to retain a dental restoration.

    The plan's review evaluates whether services meet generally accepted standards of dental practice and the member's contract; the determination of medical or dental necessity does not guarantee that the service is a covered, payable benefit under the dental plan.

    References: ADA CDT 2016; peer-reviewed dental literature and selected articles on crown-to-root ratio and biological width

    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 practicing in the relevant clinical area, and other relevant credible sources.

    Revision History

    2021-10-30RevisedLatest

    Annual Review; no specific clinical policy changes documented. Policy status indicates Revised; publish/effective date 01/01/2022.

    Policy Summary
    PayerEmpire Bluecross
    PolicyClinical Crown Lengthening
    Policy CodePolicy 04-206
    Change TypeRevised (Annual Review)
    Effective Date01/01/2022
    Last ReviewOct 30, 2021
    Next Review Date
    Key ActionSubmit a diagnostic radiograph documenting < 3 mm of sound tooth structure between restorative margin and alveolar crest; if radiograph is inconclusive, provide additional patient records documenting need for treatment.
    SourceLink
    On This Page
    Coverage SummaryMedically/Dentally Necessary CriteriaSituations Where Clinical Crown Lengthening Is Not Considered / Is InclusiveCodingProvider Actions / Billing GuidanceBackground & EvidenceRevision History

    Not allowed when performed for cosmetic reasons.

  1. Structural loss etiologies: Procedure performed for structural loss due to wear, erosion, attrition, abrasion, or abfraction.

    Not considered for these etiologies.

  2. Troughing for crown prep or margin visualization: Troughing of soft tissue as part of crown preparation or to visualize margins for impressions.

    Does not meet CDT descriptor for D4249.

  3. Same-date as crown (inclusive): If crown lengthening is performed on the same date of service as the crown (final crown), D4249 is considered inclusive with the crown.

    D4249 not separately payable when done same date as crown.

  4. Inclusive with osseous surgery: When performed in conjunction with osseous surgery for periodontal disease, the crown lengthening procedure is inclusive with osseous surgery.

    Inclusive with osseous surgery.

  5. D4274 inclusive when same date with D4249: If distal or proximal wedge procedure (D4274) performed in conjunction with D4249 on same date of service, then D4274 is considered inclusive.

    D4274 inclusive when same date with D4249.

  6. Inadequate crown-to-root ratio after procedure: If resulting bone removal yields an inadequate crown-to-root ratio, there is no benefit as long-term prognosis is compromised.

    Not covered if crown-to-root ratio inadequate after procedure.

    7. Billing Rule

    Inclusive procedures / same-day billing

    D4249 is considered inclusive and not separately payable when performed on the same date as a crown or when performed in conjunction with osseous surgery for periodontal disease; D4274 is inclusive if performed same date with D4249.

    • D4249
    • D4274
    Documentation Required

    Periodontal charting may be required

    Periodontal pocket charting may be requested as part of dental review.