CurrentUnitedHealthcarePolicy DCP024.13

Other Restorative Procedures

Defines indications and coding for repair, recement/rebond, reattachment of tooth fragments, and coping related to single-tooth indirect restorations for UnitedHealthcare dental plans; intended for providers determining coverage and billing.

Policy Summary

PayerUnitedHealthcare

PolicyOther Restorative Procedures

Policy CodePolicy DCP024.13

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review Date

Key ActionRefer to the member specific benefit plan document to determine whether prior authorization is required for listed CDT codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10procedure codes listed

1page count

CA AB2585nonpharm pain mgmt referenced

Coverage Criteria

Medical Necessity Criteria

Covered when the procedure meets the following indications:

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Applicable Procedure Codes

Applicable CDT Procedure CodesCPT

D2910	Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration.
D2915	Re-cement or re-bond indirectly fabricated or prefabricated post and core.
D2920	Re-cement or re-bond crown.
D2921	Reattachment of tooth fragment, incisal edge or cusp.
D2971	Additional procedures to construct a new crown to fit under existing partial denture framework.
D2975	Coping.
D2980	Crown repair necessitated by restorative material failure.
D2981	Inlay repair necessitated by restorative material failure.
D2982	Onlay repair necessitated by restorative material failure.
D2983	Veneer repair necessitated by restorative material failure.

1–10 of 11

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Provider Actions & Billing Notes

Prior Authorization

Prior Authorization per Member Plan

Prior authorization requirements vary by member and plan. Providers must always check the member-specific benefit plan document to determine whether prior authorization is required before rendering services.

Check the member-specific benefit plan document and applicable federal/state mandates before submitting authorization requests.

Documentation Required

Provider Action: Reference Member-Specific Plan

Providers must reference the member-specific benefit plan when submitting claims and authorizations. Ensure submitted documentation aligns with the member’s plan terms and any applicable mandates to avoid denials.

Include the member plan name/identifier and relevant benefit language in the clinical documentation when required.
If there is a conflict between this policy and the member-specific plan, follow the member-specific plan.

Denial Risk

Benefit Coverage Determined by Member Plan

Benefit coverage is determined by the member-specific plan. Listing procedure codes in this policy does not guarantee coverage or payment; providers should verify benefits and billing rules prior to providing services.

Codes listed here (e.g., D2910, D2920, D2980, D2999) are for reference only and may not be exhaustive.
Lack of prior authorization or documentation consistent with the member plan may result in claim denial.

Billing Rule

Provider Actions & Documentation Reminder

Follow any additional provider-facing instructions in the member-specific plan or payer communications. Maintain thorough clinical records to support medical necessity and compliance with plan requirements.

Retain documentation that demonstrates medical necessity and alignment with the member’s benefit terms.
Monitor plan updates and payer notices for changes that affect billing or authorization processes.

Background

Single-tooth indirect restorations (inlays, onlays, crowns, veneers) can fail by separation from cement or bond or by fracture of incisal edges or cusps; when a tooth fracture is confined to enamel and dentin with loss of structure, reattachment of the original fragment may be considered. Such reattachment is intended only for fractures that do not extend into the tooth root; fractures involving roots are excluded from reattachment and require alternative restorative or surgical management.

Key Definitions

inv-09: Reattachment of Tooth Fragment — definition and indication limits (enamel/dentin confined; not for root fractures)

DefinitionReattachment of tooth fragment: procedure to reattach a fractured tooth fragment when the fracture is confined to enamel and dentin with loss of tooth structure.

Indication (covered)Indicated for tooth fractures that are confined to enamel and dentin with loss of structure.

Not indicated (limit)Not indicated for fractures involving tooth roots.

inv-10: Coping — definition describing thin covering/substructure for restorations

DefinitionCoping: a thin covering of the coronal portion of the tooth, usually without anatomic conformity; custom made or prefabricated thimble-shaped core or base layer designed to fit over a natural tooth preparation, post core, or implant abutment to act as a substructure for a restoration or prosthesis.

UsesUsed as a substructure onto which other components are added to give final form to a restoration or prosthesis; can be definitive or part of a transfer procedure.

Clinical considerationConsidered inclusive to crown/abutment preparation unless a separate procedure is needed because insufficient natural tooth structure remains or to allow a common path of insertion when retainer teeth are tipped or misaligned.