ModifiedWellpointPolicy 03001

Crowns, Inlays, and Onlays

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Dental coverage consideration and documentation requirements for indirect restorations, including crowns, inlays, and onlays, subject to the member’s contract and plan-specific provisions.

Policy Summary

PayerWellpoint

PolicyCrowns, Inlays, and Onlays

Policy CodePolicy 03001

Change TypeRevised

Effective Date01/01/2025

Last ReviewSep 6, 2024

Next Review DateN/A

Key ActionSubmit current, dated pretreatment diagnostic radiographs taken within 12 months that include the radiographic apex.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsPretreatment radiograph currency

1:1Crown-to-root ratio risk threshold

1/3 opposing toothThird-molar occlusal contact

0.5–1.2 mmIdeal endodontic obturation

32Numbered criteria

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ModifiedWellpointPolicy 03001

Crowns, Inlays, and Onlays

Customize your policy alerts

Sign up for wellpoint Policy 03001 alerts

Get alerted when Policy 03001 changes without checking for updates manually.

Monitor payer policy activity

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Dental coverage consideration and documentation requirements for indirect restorations, including crowns, inlays, and onlays, subject to the member’s contract and plan-specific provisions.

Policy Summary

PayerWellpoint

PolicyCrowns, Inlays, and Onlays

Policy CodePolicy 03001

Change TypeRevised

Effective Date01/01/2025

Last ReviewSep 6, 2024

Next Review DateN/A

Key ActionSubmit current, dated pretreatment diagnostic radiographs taken within 12 months that include the radiographic apex.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsPretreatment radiograph currency

1:1Crown-to-root ratio risk threshold

1/3 opposing toothThird-molar occlusal contact

0.5–1.2 mmIdeal endodontic obturation

32Numbered criteria

Coverage Criteria

Core structural eligibility

Covered consideration requires the applicable tooth-specific structural criteria.

Tooth-specific structural loss

Anterior tooth: Significant coronal tooth structure loss due to caries, fracture, or defective restoration and/or involvement of one or both incisal angles or a canine cusp tip.
Posterior tooth: Significant missing tooth structure due to caries, fracture, or defective restoration; a large restoration compromising function; or loss of cusp support with one or more undermined cusps.

Fracture and trauma

The structural loss must extend into dentin when the fracture indication is being evaluated.

Fracture-related structural loss: The fracture must involve missing tooth structure extending into the dentinal layer.dentinal layer

Fractured teeth caused by an external blow or blunt trauma should first be referred to the subscriber or employee medical/health plan where applicable.

Periodontal and endodontic requirements

Periodontal and endodontic status must support placement of the indirect restoration.

Periodontal and endodontic suitability: The tooth must have manageable periodontal status and no disqualifying untreated endodontic condition.

Periodontal therapy and maintenance may need to be completed or planned before approval. Untreated or unresolved periapical or periradicular pathology, unresolved deep caries near the pulp without planned endodontic therapy, internal or external resorption, and inadequate root canal obturation may prevent benefit consideration.

Endodontically treated anterior teeth

Anterior endodontically treated teeth may be considered only when the applicable structural criteria are also met.

Anterior endodontic treatment: An anterior tooth treated by endodontic therapy must meet the anterior structural criteria, including significant loss of tooth structure involving the incisal angles when applicable.

Root canal therapy alone does not qualify.

Primary teeth, third molars, and splinting

Special tooth and diagnostic situations require the listed additional conditions.

Special situations: The applicable special-situation requirements must be met.

For primary teeth in adult dentition, radiographs must show an intact root, adequate periodontal support without active disease, occlusal function with an opposing tooth, and no permanent successor or an unlikely-to-erupt successor. For third molars, the completed crown must be in occlusal function with an opposing tooth, generally contacting at least one-third of the opposing tooth. Splinted teeth must independently merit indirect restorations under the policy criteria.

Cracked tooth syndrome

For cracked tooth syndrome, all applicable diagnostic and restorative conditions must be documented.

Cracked tooth syndrome: Document symptoms and their onset, frequency, and duration; pain or discomfort on biting or release with clinically verified pressure; oral evaluation and contributing factors; diagnosis; endodontic evaluation showing no irreversible pulpal involvement requiring endodontic therapy; restorability with significant structural compromise; and no root fracture below the soft-tissue attachment level on radiographs.

The plan may request additional clarification; a narrative alone is not considered appropriate review material.

Developmental grooves or craze lines confined to enamel do not qualify for coverage of an indirect restoration.

Indirect restorations placed to repair complications from attrition, abrasion, erosion, or abfraction are not a covered benefit when excluded by the member’s contract.

Full-coverage indirect restorations placed solely for occlusal alterations, changes in vertical dimension, treatment of temporomandibular joint disorder (TMD), or craniomandibular disorders do not meet benefit criteria.

Benefits are not considered for closure of contacts unless the contact closure is caused by caries, tooth fracture, or a defective restoration, or when caries extends into the furcation.

Benefits are not considered when subgingival or subosseous caries may compromise supracrestal tissue attachment without addressing the required restorative and periodontal considerations.

A tooth that is discolored, misshapen, or cosmetically compromised does not meet coverage criteria when there is no qualifying structural disease. Developmental or congenital defects and cosmetic compromise alone are not covered indications.

A crown placed solely to correct occlusion, alter vertical dimension, or treat TMD or craniomandibular disorders does not meet criteria for benefits.

Coding and Clinical Thresholds

CDT procedures applicable to crowns, inlays, and onlaysCPT

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

1–10 of 44

1/5

Pretreatment radiographs

CurrencyWithin 12 months

Required imageCurrent, dated pretreatment diagnostic radiographic image(s)

Required coverageThe image(s) must include the radiographic apex

Ideal endodontic obturation

Target locationAs close as possible to the apical constriction

Ideal distance0.5–1.2 mm from the apical constriction

Additional requirement

Documentation and Provider Actions

Prior Authorization

Periodontal Clearance Before Approval

Before approval, ensure definitive periodontal therapy and periodontal maintenance have been successfully performed, or include periodontal therapy in the treatment plan. The plan may evaluate treatment success before approving the indirect restoration.

Address uncontrolled or untreated periodontal disease, radiographic or periodontal-charting evidence of bone loss, and furcation involvement before requesting approval.

Documentation Required

Pre-determination Periodontal Review

For benefit determination, the plan may request the patient’s current periodontal status and periodontal-treatment history, including tooth mobility and continuous maintenance therapy.

Provide a current, dated 6-point periodontal chart when requested.
Document periodontal therapy and maintenance outcomes.

Clinical Background

Crowns restore extensively damaged or weakened coronal tooth structure by surrounding the remaining coronal portion. Inlays and onlays are indirect restorations; an onlay covers one or more cusp tips and adjoining occlusal surfaces without covering the entire crown, helping preserve healthy tooth structure. Coverage consideration depends on structural loss, periodontal and endodontic status, function, restorability, and the member contract.

Definitions

Onlay

Restoration typeIndirect restoration

CoverageOne or more cusp tips and adjoining occlusal surfaces

ExtentDoes not cover the entire crown portion of the tooth

Dental crown

Restoration typeDental crown

PurposeRestores damaged or weakened tooth structure

Structure surroundedThe remaining coronal portion of the tooth

Policy Summary

PayerWellpoint

PolicyCrowns, Inlays, and Onlays

Policy CodePolicy 03001

Change TypeRevised

Effective Date01/01/2025

Last ReviewSep 6, 2024

Next Review DateN/A

Key ActionSubmit current, dated pretreatment diagnostic radiographs taken within 12 months that include the radiographic apex.

SourceLink

On This Page

Appropriate fill density

Gross overextension

Condition to avoidGross overextension of the root canal filling

ThresholdOver 2 mm beyond the canal

Policy directionGross overextension should be avoided

Endodontic underfill

Condition to avoidEndodontic underfill

ThresholdShort over 2 mm

Applicable conditionIn the presence of patent canals

Third-molar occlusal function

Tooth typeThird molar

Functional requirementThe completed crown must be in occlusal function with an opposing tooth

Minimum contactAt least 1/3 of an opposing tooth

Crown-to-root ratio

MeasurementCrown-to-root ratio

ThresholdPoorer than 1:1

Coverage impactCreates a less than ideal situation and may be denied

Documentation Required

Pretreatment Radiographs Required

Submit current, dated pretreatment diagnostic radiographs obtained within 12 months. Images must include the radiographic apex of the tooth or teeth being treated.

Use diagnostic images that are current at the time of submission.
Ensure the radiographic apex is captured.

Documentation Required

Supporting Clinical Records

Include supporting records when requested, including clinical chart notes, intraoral photographs, current dated 6-point periodontal charting, and the history of periodontal therapy.

Chart notes should support the diagnosis and proposed indirect restoration.
Include periodontal documentation and treatment history when relevant.

Documentation Required

Additional Diagnostic Support

When the indication for an initial or replacement crown, inlay, or onlay is not obvious on radiographic images, submit additional diagnostic support explaining why the indirect restoration is needed.

Include intraoral photographs of the affected tooth or teeth.
Provide clinical chart notes stating the rationale for coverage.

Unsupported block type: documentation

Documentation Required

Primary Tooth in Adult Dentition

For a primary tooth in an adult dentition, submit radiographic and periodontal evidence supporting full-coverage placement.

Radiographs must demonstrate an intact root structure and no permanent successor, or that the permanent successor is unlikely to erupt.
Document adequate periodontal support with no active periodontal disease.
Document occlusal function with an opposing tooth and that the tooth otherwise meets full-coverage criteria.

Documentation Required

Cracked Tooth Documentation

For cracked tooth syndrome, document all clinical findings needed to support the diagnosis and treatment plan in the chart and patient records.

Record oral complaints and current symptoms, including onset, frequency, and duration.
Document pain or discomfort on biting or release of biting, pressure verified clinically, oral evaluation, contributing factors, and the diagnosis.
Include endodontic evaluation showing no irreversible pulpal involvement requiring endodontic therapy.
Document that the tooth is structurally compromised by decay, fracture, or trauma and that no root fracture below the soft-tissue attachment level is shown radiographically.
The plan may request additional information; a narrative alone is not appropriate review material.

Denial Risk

Noncovered Wear-related Complications

Indirect restorations placed to repair complications from attrition, abrasion, erosion, or abfraction are not a covered benefit, subject to contract provisions.

Do not submit wear-related complications as a covered indication unless the applicable contract provides otherwise.

Denial Risk

Cosmetic and Occlusal Indications

Benefits are not available for indirect restorations used solely for discolored, misshapen, or compromised cosmetics, developmental or congenital defects, occlusal alterations, changes in vertical dimension, TMD, or craniomandibular disorders.

Benefits may also be unavailable for TMD-related restorations under the contract.
Document a qualifying structural indication rather than a cosmetic, developmental, or occlusal purpose.

Denial Risk

Poor Prognosis or Age Limitation

Assess prognosis before requesting coverage. A crown-to-root ratio poorer than 1:1 creates a less-than-ideal situation and may result in denial; age limitations are contract dependent.

Document the crown-to-root relationship and overall restorability.
Verify any applicable contract age limitation.

Denial Risk

Nonqualifying Restorative Purposes

Benefits are not available when an indirect restoration is placed solely as a survey crown or removable-partial-denture guide plane. Benefits are also not considered for contact closure unless caused by caries, tooth fracture, or a defective restoration.

Do not use a survey-crown or guide-plane function alone as the restorative indication.
Address subgingival or subosseous caries that may compromise supracrestal tissue attachment and caries extending into the furcation before requesting benefits.

Denial Risk

Periodontal and Endodontic Disease

Resolve periodontal and endodontic conditions before placement. An indirect restoration on a tooth with uncontrolled or untreated periodontal disease, untreated or unresolved periapical or periradicular pathology, or an unresolved carious lesion near the pulp without planned endodontic therapy will not be considered or may require successful treatment first.

Evaluate endodontic obturation, including significant overextension or underfill, when relevant.
Teeth with internal or external resorption may not qualify.
Follow the applicable endodontic policy for unresolved pulpal or periapical conditions.

Billing Rule

Separate Provisional Crown Billing

A temporary or provisional crown is a component of the final restoration and is not eligible for a separate benefit.

Do not bill the provisional crown as a separate covered restoration.

Inlay

Restoration typeIndirect restoration

IndicationUsed for teeth with less damage

Conservation benefitPreserves the remaining healthy tooth structure

Delivery date

DefinitionDate of initial cementation or bonding of the indirect restoration

Cement typeThe type of cement used does not determine the delivery date

Bonding agentThe bonding agent used does not determine the delivery date