CurrentEmpire BluecrossPolicy N/A

Crowns, Inlays, and Onlays - Indirect Restorations Coverage Criteria

Policy governing indications, documentation, and coverage considerations for indirect restorative dental procedures (crowns, inlays, onlays) for individual teeth under Empire Bluecross dental plans; applies to providers submitting claims and requests for benefit determination.

Policy Summary

PayerEmpire Bluecross

PolicyCrowns, Inlays, and Onlays - Indirect Restorations Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionSubmit current (within 1 year), dated pretreatment radiographs (including the radiographic apex) and supporting clinical documentation for prior authorization or benefit determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

31+CDT codes listed

1yrRadiograph recency

>=15Coverage criteria items

NCState applicability

Coverage Criteria for Indirect Restorations

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General coverage criteria for indirect restorations

Covered when ALL of the following apply (contract dependent):

Tooth structural criteria: Tooth demonstrates significant loss of coronal tooth structure due to caries, fracture, or defective restoration; for anterior teeth this includes involvement of one or both incisal angles or cusp tip (canines); for posterior teeth this includes missing tooth structure, large restorations compromising function, or undermined cusps (one or more).significant loss

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Trauma-related fractures: Fractures from external blunt trauma should first be referred to the member's medical/health plan; when considered under dental benefit, the fracture must involve missing tooth structure that extends into dentin.dentin involvement

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Periodontal status: Tooth must have controlled periodontal health or documentation that definitive periodontal therapy and maintenance have been successfully performed or are planned; current dated 6‑point periodontal charting and history of periodontal therapy may be requested prior to benefit determination.no uncontrolled periodontal disease

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Endodontic & periapical status: No untreated or unresolved periapical or periradicular pathology; placement on a tooth with unresolved caries in close proximity to the pulp requires planned endodontic therapy; placement on teeth with internal or external resorption may not be considered. See Dental Policy 03-001 Endodontic Therapy.resolved pathology or planned therapy

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Cracked tooth syndrome specific requirements: For cracked tooth syndrome, the chart must document patient's symptoms (onset, frequency, duration), pain on biting verified clinically, oral evaluation of contributing factors, documented diagnosis, endodontic evaluation showing no irreversible pulpal involvement, tooth structural integrity adequate for restoration, and no root fracture below the soft tissue attachment on radiographs. Additional information may be requested.all items documented

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Occlusion & function: Completed crown must be in occlusal function with an opposing tooth (third molars must occlude with at least one‑third of an opposing tooth when applicable); crowns placed solely to alter occlusion or to treat TMJ/craniomandibular disorders do not meet criteria.occluding function

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Temporary/provisional crowns: A temporary or provisional crown is considered a component of the final restoration and is not eligible for separate benefit.N/A

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Not covered / exclusions

The following conditions are explicitly not covered or are contract dependent exclusions:

Not covered reasons: Indirect restorations placed for repair of complications from attrition, abrasion, erosion, or abfraction; restorations placed solely for cosmetic reasons (discoloration, misshapen teeth); crowns placed to correct developmental or congenital defects; crowns placed to treat TMD/craniomandibular disorders; restorations placed solely as survey crowns for removable partial dentures; closure of contacts unless caused by caries, fracture, or defective restoration; crowns when subgingival/subosseous caries may compromise supracrestal tissue attachment without addressing restorative/periodontal needs; and teeth with caries into the furcation. Benefits may be contract dependent for some exclusions.N/A

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Primary teeth in adult dentition

Coverage criteria for primary teeth retained in adult dentition:

Primary tooth criteria: Radiographic images must demonstrate intact root structure, adequate periodontal support with no evidence of active periodontal disease, occlusal function with an opposing tooth, and no permanent successor present or the permanent successor is unlikely to erupt. When these criteria are met, full coverage indirect restoration placement may be considered.radiographic demonstration

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Indirect restorations placed solely to repair complications from attrition, abrasion, erosion, or abfraction are generally not covered under most group contracts. Similarly, restorations performed only for cosmetic reasons (for example, to correct discoloration or a misshapen tooth) are not considered a covered benefit. Providers should confirm group contract language, as some exclusions and exceptions are contract dependent.

Additional exclusions related to cosmetic or nonfunctional indications include crowns placed to correct developmental or congenital defects, crowns used solely as survey crowns for removable partial dentures, and restorations intended only to close contacts unless the contact closure is due to caries, fracture, or a defective restoration. When subgingival or subosseous caries may compromise supracrestal tissue attachment (formerly "biologic width") or when caries extends into a furcation, benefits will not be considered unless the periodontal/restorative issues are addressed.

Placement of an indirect restoration is covered only when the clinical criteria demonstrating significant structural loss of the tooth are met and when supporting conditions are acceptable. A tooth must show extensive coronal tooth structure loss from caries, fracture, or defective restoration; this determination is contract dependent and must be documented.

Before approval, the tooth’s endodontic status and periodontal stability must be considered. Indirect restorations will not be considered on teeth with untreated or unresolved periapical/periradicular pathology or with unresolved caries in close proximity to the pulp unless endodontic therapy is planned. Benefits may also be precluded for teeth with internal or external resorption. Functional requirements must be met — crowns should be in occlusal function with an opposing tooth (for third molars at least 1/3 of an opposing tooth must be occluding).

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization/Benefit Determination

Prior authorization/benefit determination may be required and is contract dependent. Documentation must demonstrate that the indirect restoration meets coverage criteria and generally accepted standards of dental care at the lowest cost that properly addresses the patient's condition. Note: depending on group contracts, benefits may be payable based on either the preparation date or the cementation date of the permanent indirect restoration.

Prior authorization may be required — contract dependent
Benefits payable date may be preparation or cementation date — check group contract

Note

Alternate Restoration Consideration

Before approving an indirect restoration, the plan may require consideration of alternate restorations (for example, composite or amalgam). Approval is contract dependent and the treating dentist should document why an indirect restoration is necessary instead of a less costly alternative.

Alternate restoration (composite or amalgam) may be required prior to approval — group contract dependent
Crowns not covered for cosmetic reasons, discoloration, misshape, or solely to improve appearance

Documentation Required

Required Documentation for Review

Submit current (within 1 year), dated, and properly identified pretreatment radiographic images that include the radiographic apex. When radiographs alone do not demonstrate the indication, include adjunctive documentation such as intra-oral photographs, clinical chart notes stating the rationale, current dated 6‑point periodontal charting, and history of periodontal therapy as applicable.

Pretreatment radiographs must include radiographic apex and be dated within 1 year
Include intra-oral photos and clinical notes when radiographs are insufficient
Current dated 6‑point periodontal charting and periodontal history may be requested

Denial Risk

Common Denial Triggers

Claims may be denied when indirect restorations are placed for conditions that are excluded or not supported by documentation. Common denial triggers include placement for attrition/abrasion/erosion/abfraction complications, for cosmetic reasons (discoloration, misshape), for developmental or congenital defects, solely to act as survey crowns for removable partial dentures, or when periodontal/endodontic status or other clinical prerequisites are not met.

Not covered when placed for attrition, abrasion, erosion, or abfraction — per most group contracts
Not covered for cosmetic purposes (discoloration, misshape) or developmental/congenital defects
Not covered if periodontal disease is uncontrolled or if significant periapical pathology/untreated endodontic issues exist
Replacement for metal allergy requires physician documentation and allergy report
Delivery date considered date of initial cementation/bonding; payment rules may be contract dependent

Policy Revision History

2024-01-01policy_effective_dateLatest

Policy publish/effective date updated to 01/01/2024 with revised clinical criteria and guidance for indirect restorations.

2023-08-23annual_review

Annual review completed; committee approved revisions to criteria and policy language.

2022-10-21annual_revision

Annual revision performed and approved by committee to update criteria verbiage and references.

2021-10-06annual_revision

Annual revision carried out to update policy content and maintain clinical currency.

2020-12-04annual_revision

Annual revision conducted and documented by the committee.

2020-08-26annual_review

Annual review recorded by the committee to confirm continued appropriateness of policy guidance.

2019-07-03revision

Policy verbiage updated in a committee-approved revision.

2019-04-22revision

Criteria numbering revised and approved by SME (Kahn).

2019-03-04revision

Policy converted to external-facing format in a revision approved by committee.

2019-03-04revision_note_duplicate

(Historic entry) revision noted in revision history; committee recorded changes.

D2510	Metallic one surface Inlay
D2520	Inlay metallic two surface
D2530	Metallic - three or more surface Inlay
D2542	Onlay
D2543	Onlay metallic - three surface
D2544	Onlay metallic - four or more surfaces
D2610	Inlay porcelain/ceramic one surface
D2620	Porcelain/ceramic two surfaces Inlay
D2630	Inlay porcelain/ceramic - three surfaces
D2642	Onlay porcelain/ceramic two surfaces

D2662	Onlay resin-based composite two surface
D2663	Onlay resin-based composite three surface
D2664	Onlay resin-based composite four or more surfaces
D2710	Crown resin-based composite (indirect)
D2712	Crown - resin based composite (indirect)
D2720	Crown resin with high noble metal
D2721	Crown resin with predominantly base metal
D2722	Crown resin with noble metal
D2740	Crown porcelain/ceramic substrate
D2750	Crown porcelain fused to high noble metal

OpenPayer

Crowns, Inlays, and Onlays - Indirect Restorations Coverage Criteria

Coverage Criteria for Indirect Restorations

Example CDT Codes for Inlays/Onlays and Crowns

Provider Requirements, Prior Authorization, and Documentation

Key Definitions

Background and Clinical Context

Policy Revision History