Clinical Crown Lengthening
Policy governing clinical indications, criteria, and coding guidance for clinical crown lengthening procedures for dental providers and plan reviewers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medical necessity criteria
Covered when ALL of the following are met
Primary coverage criteria
- Restorative necessity: Procedure is necessary to allow a restorative procedure where the proposed restoration margin would violate the periodontal attachment apparatus.
- Radiographic documentation: A current (<= 12 months), dated, diagnostic, pretreatment radiograph documents less than three millimeters of sound natural tooth structure between the restorative margin and the alveolar crest.
- Clinical environment: Procedure is performed only in a periodontally healthy environment.
- Surgical technique: Procedure includes reflection of a full-thickness flap and removal of hard (osseous) and soft (gingival) tissue with alteration of the crown-to-root ratio.
- Tooth type and indications: Procedure is for treatment of natural teeth only and is considered only when subgingival caries or fracture requires removal of soft and hard tissue to enable restoration; not for treatment of teeth with structural loss due to wear, erosion, attrition, abrasion, or abfraction; not to correct congenital or developmental defects; not for cosmetic reasons.
- Concurrent periodontal procedures: Not performed in conjunction with any periodontal procedure that addresses treatment for unhealthy periodontal tissues within the same quadrant on the same date of service (these are exclusionary).
- Crown-to-root ratio risk: If resulting bone removal would produce an inadequate crown-to-root ratio such that long-term prognosis is compromised, the procedure will not be considered beneficial and will not be covered.
Clinical crown lengthening will not be considered when performed in conjunction with any periodontal procedure that addresses treatment for unhealthy periodontal tissues within the same quadrant on the same date of service. Examples include, but are not limited to, gingivectomy, frenectomy, distal reduction, grafting, and scaling and root planing; these procedures are considered integral components of crown lengthening when addressing unhealthy periodontal tissues and therefore are exclusionary for separate consideration on the same date and in the same quadrant.
Clinical crown lengthening is not allowed when performed for cosmetic reasons or to correct congenital or developmental defects; such uses are considered elective. The procedure is also not considered for treatment of teeth with structural loss due to wear, erosion, attrition, abrasion, or abfraction.
Coding and Billing
| D4249 | Clinical crown lengthening hard tissue |
| D4274 | Mesial/distal wedge procedure |
Provider Actions and Documentation
Prior authorization / coverage determination
Coverage determination requires submission of required radiographs and clinical records showing that the procedure meets generally accepted standards of dental practice; check the member contract for benefit coverage.
- Submit dated diagnostic pretreatment radiographs and clinical records as specified by the plan.
- Verify member contract for benefit coverage prior to scheduling.
Inclusive procedure — D4274 with D4249
Mesial/distal wedge procedure (D4274) performed in conjunction with D4249 on the same date of service is considered inclusive and is not paid separately.
- Do not bill D4274 separately when performed with D4249 on the same date.
Required diagnostic radiograph
A current (within 12 months), dated, diagnostic pretreatment radiograph must be submitted documenting less than three millimeters of sound natural tooth structure between the restorative margin and the alveolar crest.
- Radiograph must be dated and no older than 12 months.
- Additional patient records may be requested when indications are not evident radiographically; periodontal charting may be required.
Denial risk — concurrent periodontal therapy
Clinical crown lengthening will not be considered when performed in conjunction with any periodontal procedure that addresses treatment for unhealthy periodontal tissues within the same quadrant on the same date of service.
- Examples include gingivectomy, frenectomy, distal reduction, grafting, and scaling and root planing — these are considered integral to crown lengthening and exclusionary when addressing unhealthy periodontium.
- If performed with osseous surgery for periodontal disease, crown lengthening is considered inclusive with the osseous surgery and will not be considered separately.
Background
Clinical crown lengthening is indicated to expose adequate tooth structure in a periodontally healthy environment to allow restorative procedures when there is little or no clinical tooth structure exposed. The operation involves reflection of a full-thickness flap and removal of both hard (osseous) and soft (gingival) tissue to re-establish appropriate restorative margins and biological width, which alters the crown-to-root ratio. If resulting bone removal yields an inadequate crown-to-root ratio, the procedure is not beneficial and will not be considered.
Definitions and Standards
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