CurrentEmpire BluecrossPolicy 02 -901

Core Buildup includes post and core procedures

Policy governing when coronal core buildups and post-and-core procedures meet generally accepted standards of dental care and when benefits may be considered for Empire Bluecross members; applies to providers submitting claims for these dental services.

Policy Summary

PayerEmpire Bluecross

PolicyCore Buildup includes post and core procedures

Policy CodePolicy 02 -901

Change TypeNo material change

Effective Date01/01/2021

Next Review Date

Key ActionVerify member contract and obtain prior authorization if the plan requires review before performing core build-ups or post-and-core procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=50%minimum missing tooth structure threshold

Guideline #internal identifier

CDT 2021code set reference

Coverage criteria for core buildup and post-and-core procedures

Initial coverage criteria

Covered when ALL of the following are met for posterior teeth (separate but equivalent conditions apply for anterior teeth):

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Posterior tooth coverage criteria

Structural deficit: Significant portion (50% or more) of missing tooth structure due to caries, fracture, or defective restoration>=50%
Posterior and anterior criteria both require 50% threshold
Retention: Insufficient tooth structure coronal to the intended restorative margin for adequate retention
Must support full-coverage restoration
Crown status: A crown or abutment is existing (to be recemented) or is treatment planned
Presence or plan for crown/abutment required

Anterior tooth equivalence

Structural deficit (anterior): Significant portion (50% or more) of missing tooth structure due to caries, fracture, or defective restoration>=50%
Same numerical threshold as posterior teeth
Retention (anterior): Insufficient tooth structure coronal to the intended restorative margin for adequate retention
Must support full-coverage restoration
Crown status (anterior): A crown or abutment is existing (to be recemented) or is treatment planned
Presence or plan for crown/abutment required

Exclusions / Not covered

Not covered / contraindications (any of the following):

Exclusion conditions

Pulpal purpose: Placement intended solely for pulpal insulation, pulpal protection, undercut block-outs, or fillers to modify final restorative material
Explicitly not considered a valid indication
Periodontal compromise: Uncontrolled or untreated periodontal disease with loss of supporting bone
Teeth with active periodontal disease will not be considered
Periapical pathology: Untreated or unresolved periapical or periradicular pathology
See Endodontic Therapy policy 03-001
Resorption: Internal or external resorption
May not be considered
Developmental defects: Core build-ups performed for correction of developmental or congenital defects
Not covered
Restorative type: Core build-ups for partial coverage indirect restorations (inlays, veneers, onlays, partial crowns)
Not considered
Wear-related repair: Core build-ups placed for repair of complications from attrition, abrasion, erosion, or abfraction
Not covered

Primary tooth

Special-case criteria:

Primary tooth criteria

Same criteria as permanent tooth: Primary tooth must meet the same criteria as a permanent tooth
Primary tooth within an adult dentition only
Radiographic requirements: Radiographs must demonstrate intact root structure, adequate periodontal support with no evidence of active periodontal disease, occlusal function with an opposing tooth, and no permanent tooth successor present or the permanent successor unlikely to erupt
Required imaging to support coverage decision

Periodontal exclusion (primary): Teeth demonstrating uncontrolled or untreated periodontal disease, evidenced by loss of supporting bone, will not be considered for core build-up placement

Consider full-mouth periodontal status and history

Core build-ups intended solely for pulpal insulation, pulp protection, or pulp capping; as fillers to eliminate undercuts; for enhancement of box-form; or simply to modify or reduce the final restorative material are not considered valid indications for benefit. Similarly, core build-ups are not appropriate when periodontal or endodontic conditions are unfavorable—examples include untreated or unresolved periapical or periradicular pathology, uncontrolled periodontal disease, or internal/external resorption, which must be addressed prior to consideration of a core buildup.

Coding and tooth-structure thresholds

CDT codes (informational)CDT

D2950	core buildup, including any pins when required
D2953	each additional indirectly fabricated post same tooth
02952	post and core in addition to crown, indirectly fabricated
02954	prefabricated post and core in addition to crown
D2957	each additional prefabricated post same tooth
D2955	post removal

Missing tooth structure — coverage threshold

Threshold50% or more of coronal tooth structure missing due to caries, fracture, or defective restoration

Applies toPosterior and anterior teeth (same 50% threshold for both)

ContextRequired when insufficient tooth structure coronal to intended restorative margin for adequate retention

Provider actions, documentation, and payer steps

Prior Authorization

Prior authorization / benefit verification — Provider action

Benefits are subject to plan review and contract requirements. Prior to providing services verify benefits and obtain prior authorization when required by the member’s contract. The plan may require that services meet generally accepted standards of dental care and be provided at the lowest cost that properly addresses the patient’s condition; a determination of dental necessity does not guarantee coverage under the member’s contract.

Verify member eligibility and benefits prior to treatment.
Obtain prior authorization when required by the contract.
Consider least-cost appropriate treatment per contract terms.

Step Therapy

Alternate treatment / payer-specific step

When an indication for a core build-up is not obvious from radiographs, or when group-specific contracts restrict benefit levels, the plan may require an alternative, less extensive restoration (for example, a one‑surface restoration instead of a build-up) depending on the specific group contract provisions.

Some group contracts allow substituting a one‑surface restoration in lieu of a build‑up in specific situations (e.g., RCT through a retained crown).
Confirm allowable alternate treatments in the member’s plan documents prior to submitting claims.

Documentation Required

Required documentation

Required documentation must be submitted to support medical/dental necessity. Include the most recent, dated, and properly identified pretreatment diagnostic radiograph(s) that show the radiographic apex. Also provide clinical chart notes, intra‑oral photographs, current dated 6‑point periodontal charting, and history of periodontal therapy when applicable. If radiographs do not clearly demonstrate the need for a build‑up, include additional documentation such as clinical rationale in chart notes, intra‑oral photos, and images taken at initial restoration removal.

Most recent dated diagnostic radiographs showing the radiographic apex.
Clinical chart notes documenting rationale for core build‑up.
Intra‑oral photographs demonstrating the condition.
Current dated 6‑point periodontal charting and periodontal therapy history when relevant.
Images of initial restoration removal when radiographs are inconclusive.

Denial Risk

Common denial triggers

Claims may be denied when documentation is incomplete or when clinical criteria are not met. Common denial triggers include absence of current diagnostic radiographs (including radiographic apex), missing clinical notes or intra‑oral photos, evidence of untreated endodontic or periodontal pathology, poor crown‑to‑root ratio without full‑mouth assessment, presence of subgingival/subosseous caries compromising supracrestal tissue attachment, internal/external resorption, or when the tooth does not meet criteria for retention (e.g., primary tooth with permanent successor expected to erupt).

Missing or non‑diagnostic radiographs.
No documentation of periodontal status or therapy.
Unresolved periapical/periradicular pathology or inadequate endodontic status.
Clinical findings inconsistent with criteria for core build‑up (poor crown:root ratio, resorption, subgingival caries).
Proposed build‑up when group contract allows a less extensive alternative.

Background

A core buildup restores missing coronal tooth structure when there is insufficient tooth remaining to retain a full-coverage indirect restoration. It is performed to re-establish adequate tooth form and retention so that a crown or abutment can be placed or re-cemented, not for routine pulpal protection or cosmetic reshaping. Endodontic treatment alone does not automatically indicate the need for a core buildup; the clinical decision depends on the extent of coronal tooth loss and the tooth’s ability to support the planned restoration.

Definitions

Core buildup — definition

DefinitionRestoration of coronal tooth structure to retain a full-coverage indirect restoration when insufficient tooth remains

Not an indicationNot intended for pulpal insulation, filler to eliminate undercuts or box form, or smoothing concave irregularities

Coverage requirementMust support retention of a crown or abutment that is existing or treatment planned

Supracrestal tissue attachment (STA) — definition & relevance

DefinitionSupracrestal tissue attachment (STA) — the biological dimension formerly called biologic width that must be preserved when considering restorative procedures

RelevanceBenefits will not be considered when subgingival/subosseous caries may potentially compromise STA without addressing restorative and periodontal considerations

Implication for treatmentPeriodontal health must be evaluated; uncontrolled periodontal disease or loss of supporting bone excludes the tooth from core buildup consideration