CurrentEmpire BluecrossPolicy 02-901

Core Buildup includes post and core procedures

Defines when core buildups and post-and-core procedures for teeth meet generally accepted standards of dental care and when benefits may be considered under the dental plan; applies to providers submitting claims and documentation for members covered by the plan.

Policy Summary

PayerEmpire Bluecross

PolicyCore Buildup includes post and core procedures

Policy CodePolicy 02-901

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateAug 23, 2024

Key ActionVerify member contract coverage and prior authorization requirements and submit required documentation including diagnostic radiographs taken within 1 year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6CDT codes listed

Radiographs ≤1yrDocumentation requirement

Posterior & anteriorTeeth-specific coverage

<1:1 flaggedCrown:root

Medically Necessary Coverage Criteria

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Medically necessary coverage criteria

Covered when ALL of the following are met for posterior or anterior teeth (where specified):

General indications: A significant portion of missing tooth structure due to caries, fracture, or defective restoration; and insufficient tooth structure coronal to the intended restorative margin for adequate retention; and a crown or retainer is either existing (to be recemented/rebonded) or is treatment planned.

Applies to posterior and anterior teeth as specified in policy.

Anterior-tooth specific note: For anterior teeth, endodontic treatment alone does not automatically constitute necessity; the same general indications (significant missing tooth structure, insufficient coronal tooth structure, and existing or planned crown/abutment) must be met.

See chunk 4 lines 7-10.

Endodontic considerations: The endodontic status must be acceptable: untreated or unresolved periapical or periradicular pathology, unresolved lesion near the pulp without planned endodontic therapy, overfill/underfill or poor condensation of root canal obturation, and internal or external resorption may preclude benefit.

See related policy 03-001 for endodontic requirements.

Periodontal and structural contraindications: Teeth demonstrating uncontrolled or untreated periodontal disease evidenced by loss of supporting bone; subgingival or subosseous caries that may compromise supracrestal tissue attachment; or unfavorable crown-to-root ratios (poorer than 1:1) without comprehensive assessment may not be considered for benefit.

Full‑mouth and patient‑specific factors must be assessed.

Primary tooth (in adult dentition): To be considered, a primary tooth must meet the same criteria as a permanent tooth: radiographic evidence of intact root structure, adequate periodontal support with no active periodontal disease, occlusal function with an opposing tooth, and radiographs showing no permanent successor or that the successor is unlikely to erupt.

Applies when treating primary teeth in an adult dentition.

Explicit non‑covered indications: Core buildups placed for pulp capping/insulation, undercut block‑outs, enhancement of box form, fillers to eliminate undercuts or reduce filler, repair of attrition/abrasion/erosion/abfraction, correction of developmental or congenital defects, provision for partial‑coverage indirect restorations (inlays, veneers, onlays), or when the diagnosis is cracked tooth syndrome (which may not qualify) are not considered benefits.

These exclusions are explicitly listed in the policy.

Procedure-specific criteria

Additional procedural considerations:

Third molar (wisdom tooth) criteria: For third molars, the completed crown must be in occlusal function with an opposing tooth (must occlude with at least one‑third of an opposing tooth). Exceptions may apply for crowns supporting removable or fixed partial dentures per group contract.

Group‑contract dependent.

Furcation involvement: Benefits for indirect restorations (including core buildups intended to retain indirect restorations) will not be considered when the tooth exhibits caries into the furcation.

Furcation caries is an exclusion for indirect restoration benefits.

Alternative benefit arrangements: Depending upon group contracts, a buildup may be alternated to a one‑surface restoration in instances where root canal therapy is performed through a retained existing crown.

Subject to specific group contract terms.

Core buildups are not considered medically necessary when performed solely for purposes that do not restore tooth form required to retain a full‑coverage indirect restoration. Examples of exclusions include placement for pulp capping, pulpal insulation or protection, as fillers to eliminate undercuts or to enhance box form, to fill concave irregularities, or to repair complications from attrition, abrasion, erosion, or abfraction. Benefits are also not considered when used for partial‑coverage indirect restorations (for example, inlays, onlays, veneers) or when the tooth has subgingival/subosseous caries that may compromise supracrestal tissue attachment without appropriate periodontal/restorative management.

Core buildups may be excluded where periodontal or endodontic conditions contraindicate retention: teeth with uncontrolled or untreated periodontal disease evidenced by loss of supporting bone, teeth with untreated or unresolved periapical/periradicular pathology, teeth with overfill/underfill root canal obturation or internal/external resorption, and cases where a diagnosis (e.g., cracked tooth syndrome) does not meet the criteria for benefit. For primary teeth in adult dentition, radiographic and clinical criteria (intact roots, adequate periodontal support, occlusal function, and no expected permanent successor) must be met or benefits will not be considered.

Core buildups performed primarily as pulpal insulation, pulp capping, undercut block‑outs, or box‑form enhancement are excluded from coverage because these procedures do not create or restore the coronal tooth structure necessary to retain an indirect full‑coverage restoration. The policy explicitly lists these uses—placement to protect the pulp or merely to fill undercuts or reshape preparation forms—as situations where a buildup will not be considered for benefit.

Similarly, procedures billed as core buildups when intended to correct developmental or congenital defects, to serve as fillers for reduction of structural irregularities, or to support partial‑coverage restorations (inlays, veneers, onlays) are not considered medically necessary. Documentation must demonstrate that the buildup is required to provide adequate coronal structure for a planned or existing crown or retainer; absent that indication, the service is excluded.

Billing and Code Information

CDT codes listedmixed

D2950	core buildup, including any pins when required
D2952	post and core in addition to crown, indirectly fabricated
D2953	each additional indirectly fabricated post same tooth
D2954	prefabricated post and core in addition to crown
D2957	each additional prefabricated post same tooth
D2955	post removal

CDT codes listed (system specific)CPT

D2950	core buildup, including any pins when required
D2952	post and core in addition to crown, indirectly fabricated
D2953	each additional indirectly fabricated post same tooth
D2954	prefabricated post and core in addition to crown
D2957	each additional prefabricated post same tooth
D2955	post removal

Provider Requirements and Actions

Prior Authorization

Verify benefit coverage and authorization

Verify benefits and prior authorization requirements with the member's plan before providing core buildup services. Coverage is subject to the member's contract and may require prior authorization or additional documentation to determine whether the service meets the plan's definition of generally accepted standards of dental care. The determination that a service is dentally necessary does not guarantee it is a covered benefit under the member's contract.

Check member eligibility and plan-specific benefit language for core buildups and related procedures prior to treatment.
Obtain prior authorization when required by the group contract or benefit plan; follow payer-specific submission instructions.

Denial Risk

Triggers for denial

Common reasons claims for core buildups are denied include submissions that do not meet clinical indication criteria or lack required supporting documentation. Claims for procedures performed for pulp capping/insulation, undercut block-outs, enhancement of box-form, filler purposes, or for partial-coverage indirect restorations (e.g., inlays/onlays/veneers) are not considered for benefit.

Submitted for pulp capping, insulation, or protection of the pulp — not covered.
Placed to eliminate undercuts, block-outs, or purely to enhance box-form — not covered.
Submitted for repair of complications from attrition, abrasion, erosion, or abfraction — not covered.
Core buildups for partial coverage indirect restorations (inlays/onlays/veneers) — not covered.
Teeth with untreated/unresolved periapical or periradicular pathology, overfill/underfill root canal obturation, internal/external resorption, uncontrolled periodontal disease, or subgingival/subosseous caries compromising supracrestal tissue attachment — may be denied if not addressed.

Documentation Required

Required documentation

Submit current (within 1 year), dated, pretreatment diagnostic-quality radiographic image(s) that include the radiographic apex with all prior authorization or claim submissions for core buildups. When radiographs do not clearly demonstrate need, provide adjunctive documentation such as clinical chart notes describing rationale, intra-oral photographs, and images of the tooth after existing restoration removal.

Radiographic images must be dated and include the radiographic apex (within 1 year).
When indication is not obvious on radiograph, include clinical chart notes, intra-oral photos, and other supporting documentation.
If endodontic status or periodontal status affects eligibility, include relevant notes and imaging (see related endodontic/periodontal policies).

Key Definitions

inv-11: Core buildup — definition and intended purpose

DefinitionRestoration that builds up coronal tooth structure to retain an indirect full-coverage restoration; not intended for pulpal insulation, to fill undercuts or box-form, or to fill concave irregularities.

Intended purposeProvides sufficient coronal tooth structure and retention when there is insufficient remaining tooth structure to support a full-coverage indirect restoration.

Not intended usesNot for pulpal insulation or protection, not to eliminate undercuts (filler/block-out), not to enhance box-form, and not to fill concave irregularities in a tooth preparation.

Clinical contextUsed when a significant portion of tooth structure is missing from caries, fracture, or defective restoration and insufficient coronal tooth structure exists coronal to the intended restorative margin for adequate retention.

inv-12: Crown-to-root ratio consideration — guidance when crown:root is unfavorable (< 1:1) and assessment required

ThresholdUnfavorable crown-to-root ratios poorer than 1:1 are flagged and require additional assessment.

Required assessmentAssess the patient's full-mouth dental condition, medical history, dental history, periodontal history and continuing care, age, and occlusion when crown:root is poorer than 1:1.

Potential impact on benefitA crown-to-root ratio poorer than 1:1 may reduce the likelihood that a core buildup will be considered for benefit.

Related exclusionsTeeth with unfavorable crown-to-root ratios should be evaluated alongside periodontal status and endodontic considerations before determining benefit eligibility.

Clinical Background

A core buildup is performed to restore sufficient coronal tooth structure so an indirect full‑coverage restoration (crown or abutment) can be retained. Indications include a significant portion of missing tooth structure due to caries, fracture, or defective restoration, and insufficient tooth structure coronal to the intended restorative margin to provide adequate retention. Coverage applies when a crown or retainer is existing (to be recemented/rebonded) or is treatment planned.

Endodontic therapy alone does not automatically justify a core buildup; the tooth’s endodontic status must be acceptable (no unresolved periapical pathology, no overfill/underfill obturation, and no internal/external resorption). For third molars, the completed crown must be in occlusal function with an opposing tooth (occluding with at least one‑third of an opposing tooth) for a buildup to be considered. Additionally, teeth with caries into the furcation or with uncontrolled periodontal disease are generally excluded from benefit until those conditions are addressed.

Policy Revision History

2024-01-01policy_publishLatest

Policy published with status 'Revised' and effective date 01/01/2024.

2023-08-23annual_review

Annual review completed; last review date recorded as 08/23/2023.

2022-10-21annual_review

Annual review conducted on 10/21/2022.

2022-03-15revision

Syntax corrections made to the policy on 03/15/2022.

2021-10-06annual_review

Annual review performed on 10/06/2021 (criteria wording updated prior version notes reflected).

2020-12-04annual_review

Annual review completed on 12/04/2020.

2020-08-26annual_review

Annual review completed on 08/26/2020.

2019-07-23verbiage_update

Verbiage updates made to the policy on 07/23/2019.

2019-04-22criteria_renumbering

Criteria numbering updated on 04/22/2019.