Subject: Crowns, Inlays, and Onlays Guideline #: Publish Date: 03/15/2018 Status: Revised Last Review Date: 02/06/2018

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1 Dental Policy Subject: Crowns, Inlays, and Onlays Guideline #: Publish Date: 03/15/2018 Status: Revised Last Review Date: 02/06/2018 Description This document addresses indirect restorative procedures including inlays, onlays, and partial and full crown restorations of single (or individual) teeth. Note: Please refer to the following documents for additional information concerning related topics: Crown Build-up (02-901) Endodontic therapy (03-001) Veneers (02-902) Clinical Policy-01Teeth with Poor or Guarded Prognosis Abutment Crowns and Fixed Partial Dentures (06-701) Clinical Indications An indirect restoration is necessary and appropriate for teeth that demonstrate occlusal or incisal functional deficits such as: an anterior tooth that has had root canal therapy alone does not qualify for an indirect restoration unless it can be demonstrated that there is significant loss of tooth structure; missing more than half of the coronal structure as a result of caries undermining one or more cusps; teeth that have very large defective restorations covering the cusps: where there are undermined cusps teeth that may be fractured or have cracked tooth syndrome or posterior teeth that have had root canal therapy. As it applies to appropriateness of care, dental services are: provided by a Dentist, exercising prudent clinical judgment provided to a patient for the purpose of evaluating, diagnosing and/or treating a dental injury or disease or its symptoms in accordance with the generally accepted standards of dental practice which means: o standards that are based on credible scientific evidence published in peer-reviewed, dental literature generally recognized by the practicing dental community o specialty society recommendations/criteria o any other relevant factors clinically appropriate, in terms of type, frequency and extent considered effective for the patient's dental injury or disease not primarily performed for the convenience of the patient or Dentist not more costly than an alternative service. dependent on group contract provisions, cosmetic services may not qualify for benefit coverage even though the services may be clinically appropriate.

2 If the proposed and/or rendered procedure does not meet the criteria as stated above, it will not be considered appropriate for plan benefits. An indirect restoration is not contractually benefited in situations where: occlusal or incisal function has not been compromised such as: o when a an indirect restoration is placed on a discolored or misshapen tooth; o an indirect restoration placed for repair of complications from wear, attrition, abrasion, erosion or abfraction; o an indirect restoration placed for correction of vertical dimension or for any cosmetic purposes. o An indirect restoration placed to treat TM, for periodontal, orthodontic, or other splinting purposes Note: Whether a service is covered by the plan, when any service is performed in conjunction with or in preparation for a non-covered or denied service, all related services are also either not covered or denied. Note: A group may define covered dental services under either their dental or medical plan, as well as to define those services that may be subject to dollar caps or other limits. The plan documents outline covered benefits, exclusions and limitations. The health plan advises dentists and enrollees to consult the plan documents to determine if there are exclusions or other benefit limitations applicable to the service request. The conclusion that a particular service is medically or dentally necessary does not constitute an indication or warranty that the service requested is a covered benefit payable by the health plan. Some plans exclude coverage for services that the health plan considers either medically or dentally necessary. When there is a discrepancy between the health plan s clinical policy and the group s plan documents, the health plan will defer to the group s plan documents as to whether the dental service is a covered benefit. In addition, if state or federal regulations mandate coverage then the health plan will adhere to the applicable regulatory requirement. Criteria Note: According to provider contracts, benefits are payable upon cementation/placement of the permanent indirect restoration. In the event a subscriber does not return for permanent cementation, there is no benefit as the service will be considered incomplete. Guidelines: 1. An anterior tooth must demonstrate significant loss of the coronal tooth structure (50% or more) and involvement of one or both incisal angles or cusp tip, in the case of canines. 2. A posterior tooth must demonstrate significant missing tooth structure, large restorations that compromise function, or loss of support for the cusps where the cusps are undermined (one or more cusps), or with compromised mesial or distal marginal ridges. 3. As most health plans include coverage for dental services related to accidental injury, claims for fractured teeth resulting from an external blow or blunt trauma must first be referred to the subscriber/employee s medical/health plan which covers restoration of teeth as a result of accidental injury when performed within the first 12 months post injury. If a tooth is treated for fracture, the fracture must involve missing tooth structure that extends into the dentinal layer. 4. Teeth with developmental grooves, craze lines, or stress fracture lines confined to the tooth enamel do not qualify for indirect restoration coverage. 5. Anterior and posterior teeth that have been treated by endodontic therapy will be considered for indirect restoration coverage when meeting the criteria as stated above in numbers 1 and 2. An anterior tooth that has had root canal therapy alone does not qualify for indirect restoration coverage unless it can be demonstrated that there is significant loss of tooth structure. Teeth demonstrating internal fracture without significant missing tooth structure will not be considered for indirect restoration coverage. 6. The periodontal health of teeth to be restored by indirect restoration placement is key to long term prognosis. Teeth demonstrating uncontrolled or untreated periodontal disease, evidenced by loss of supporting bone which compromises the long term prognosis will not be considered for indirect restoration placement unless the treating dentist can demonstrate that definitive periodontal therapy and periodontal maintenance have

3 been performed. Prior to indirect restoration placement, teeth with radiographically evident untreated periodontal disease must be definitively treated. The current periodontal status and history of periodontal therapy and continuous maintenance therapy may be requested prior to benefit determination. 7. Indirect restorations placed for repair of complications from wear, attrition, abrasion, erosion or abfraction are not a covered benefit according to most group contracts. 8. A tooth must exhibit significant structural loss from decay, large restorations, fracture or significant resorption defect not attributable to the aforementioned causes to be eligible for a benefit. As related to other situations, this benefit is group contract dependent. 9. The delivery date of an indirect restoration is considered the date of initial cementation, regardless of the type of cement used for placement. The type of cement used, e.g. permanent or temporary, is not a determinate for the delivery date. 10. The status of an endodontically treated tooth must be considered. Placement of an indirect restoration on a tooth with untreated or unresolved periapical or periradicular pathology will not be considered for benefit. See Dental Policy Endodontic Therapy. 11. Replacement of indirect restorations due to metal allergy/sensitivity will be considered only upon submission of documentation by a physician with the associated allergy report. 12. A temporary or provisional crown will be considered a component part of the final restoration. 13. For a primary tooth within an adult dentition to be considered for full coverage indirect restoration placement, radiographic imaging indicating no permanent successor must be evident. Radiographic image/s of the primary tooth must demonstrate an intact root structure, adequate periodontal support and occlusal function with an opposing tooth once the indirect restoration is fabricated. 14. Full coverage indirect restoration placed for occlusal alterations and/or changes in vertical dimension do not meet criteria for benefit and will not be considered. 15. For cracked tooth syndrome, an indirect restoration is appropriate only when all of the following condition(s) necessary to support the diagnosis have been met: Pain/discomfort upon biting (or release of biting) pressure verified by a clinical examination; If the tooth is vital, there is no pulpal involvement necessitating endodontic therapy; Structural integrity of the tooth must be compromised beyond the point of being able to restore the tooth to function with other restorative materials; Must not have a root fracture (vertical or horizontal) below the soft tissue attachment level; A written letter of medical necessity must be submitted by the provider describing the diagnosis, symptoms and examination results of cracked tooth syndrome For questionable cases regarding cracked tooth syndrome, Anthem may send a request letter for more detailed information requesting the following information: Description of patient s oral complaints and current symptoms including onset, frequency and duration Narrative summary of oral examination, including any contributing factors Diagnostic tests performed and the results Radiographic findings (including types of radiographs) 16. For the replacement of missing teeth that are not covered by the plan, all the above criteria will be applied to the abutment teeth when there is a missing tooth clause in the group or individual and small group contracts. Note: contracts may include a missing tooth clause or require the plan to apply alternate benefits. 17. With plans that contain a missing tooth clause where replacement of the tooth/teeth is not covered when extracted and has not been replaced prior to insurance coverage, if the missing teeth to be replaced were removed and not replaced prior to insurance coverage, there may not be benefits for the replacement of the missing teeth when a fixed partial denture (fixed bridge) is treatment planned (Group Contract dependent). A determination will be made regarding whether the abutment teeth merit indirect restorations in their own right. 18. When a fixed partial denture is treatment planned to replace teeth missing with plans that do not have a missing tooth clause, a determination will be made related to the necessity of the fixed partial denture or if an alternate benefit can be applied which is group contract dependent. In plans with alternate benefit provisions, an alternate benefit to a removable partial denture may be determined to replace all missing teeth where the abutment teeth are determined if single indirect restoration placement is merited. In the case of an alternate benefit application, the abutment teeth are determined whether they merit an indirect restoration in their own right. 19. With plans that cover the replacement of missing teeth by dental implants, the surgical placement of the dental implant and all associated services will be covered services (e.g. bone grafting, guided tissue

4 Coding regeneration, abutment head placement). However, the replacement of the missing teeth by indirect restorations over the dental implant/s may be subject to the alternate benefit provision of a group contract. Note: All dental implant services are group contract dependent. 20. Documentation for the necessity of indirect restorations placement must include a diagnostic radiographic image that includes the radiographic apex and depicts missing tooth structure (e.g. missing and fractured cusps) resulting from decay or trauma. When the necessity for indirect restoration coverage is not obvious by radiographic images, the image must be accompanied by additional diagnostic information such as intraoral photographs of the affected tooth/teeth as well as a narrative explaining any extraordinary circumstances necessitating indirect restoration coverage. 21. When splinting of indirect restorations is requested, benefits will be group contract dependent. Therefore, a fixed bridge may not be appropriate when one of the abutments has been determined to have a guarded prognosis. Splinting of teeth by indirect restorations is routinely not a covered benefit unless group contract indicates coverage. 22. For third molars, the completed crown must be in occlusal function with an opposing tooth (must occlude with at least 1/3 of an opposing tooth; exceptions may have to be considered for crowns supporting removable or fixed partial dentures. The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. CDT D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2780 D2781 D2782 D2783 D2790 Including, but not limited to, the following: Inlay metallic one surface Inlay metallic two surface Inlay metallic three or more surface Onlay metallic two surface Onlay metallic three surface Onlay metallic four or more surfaces Inlay porcelain/ceramic one surface Inlay porcelain/ceramic two surfaces Inlay porcelain/ceramic three surfaces Onlay porcelain/ceramic two surfaces Onlay porcelain/ceramic three surfaces Onlay porcelain/ceramic four or more surfaces Inlay resin-based composite one surface Inlay resin-based composite two surfaces Inlay resin-based composite three or more surfaces Onlay resin-based composite two surface Onlay resin-based composite three surface Onlay resin-based composite four or more surfaces Crown resin-based composite (indirect) Crown ¾ resin based composite (indirect) Crown resin with high noble metal Crown resin with predominantly base metal Crown resin with noble metal Crown porcelain/ceramic substrate Crown porcelain fused to high noble metal Crown porcelain fused to predominantly base metal Crown - porcelain fused to high noble metal Crown ¾ cast high noble metal Crown ¾ cast predominantly base metal Crown ¾ cast noble metal Crown ¾ porcelain/ceramic Crown full cast high noble metal

5 D2791 D2792 D2794 D2799 Crown full cast predominantly base metal Crown full cast noble metal Crown titanium Provisional crown further treatment or completion of diagnosis necessary prior to final impression CPT Unlisted dentoalveolar service ICD-10 Diagnosis K00.2 Abnormalities of size and form of teeth K02.52 Dental caries on pit and fissure surface penetrating into dentin K02.61 Dental caries on pit and fissure surface penetrating enamel K02.9 Dental caries, unspecified K03.9 Diseases of hard tissue, unspecified K08.5 Unsatisfactory restoration of tooth K08.50 Unsatisfactory restoration of tooth, unspecified K08.51 Open restoration margins of tooth K08.52 Unrepairable overhanging of dental restorative material K08.53 Fractured dental restorative material K08.56 Poor aesthetic of existing restoration of tooth K08.59 Other unsatisfactory restoration of tooth Discussion/General Information An indirect restoration is an artificial replacement all or part of the clinical crown. A variety of restorative materials can be used when the crown portion of the tooth has been damaged by decay or trauma. Placement of an indirect restoration is indicated when a tooth is compromised by extensive decay, large restorations involving at least three to four tooth surfaces, or traumatic fracture of the tooth, which results in mobility or loss of the fractured segments. Therefore, when the tooth cannot be reasonably restored to functionality either with an amalgam or resin-based composite restoration, an indirect restoration is an appropriate choice. Definitions Abutment tooth or tooth root that supports or stabilizes a bridge, denture, or other prosthetic appliance Clinical Crown the part of the tooth that projects/is visible in the oral cavity (above the gums). Cracked Tooth Syndrome (CTS) - also known as split tooth syndrome, or incomplete fracture of posterior teeth), is where a tooth has incompletely cracked but no part of the tooth has yet broken off. See Criteria Section #15. Crown a tooth-shaped artificial device placed over a tooth to cover the tooth restoring its shape and size, strength, and improve its appearance. Indirect Restoration - A restoration fabricated outside of the mouth using the dental impressions or a scan of the prepared tooth. Common indirect restorations include inlays and onlays, crowns, bridges, and veneers. It is often done in two separate visits to the dentist. References Peer Reviewed Publications:

6 1. Heyman H. Sturdevant s Art and Science of Operative Dentistry, 6th ed. St. Louis: Mosby c2013. Online Chapter 21. Bonded Splints and Bridges: pg Rosenstiel S, Land M, Fujimoto J. Contemporary Fixed Prosthodontics, 5th ed. St. Louis: Mosby c2016. Part III: Laboratory Procedures, Chapter 27 Connectors for Partial Removable Dental Prostheses; p American Academy of Prosthodontists Glossary of Prosthodontic Terms; 4. (Accessed January 14, 2016) 5. Thompson V. Contemporary Fixed Prosthodontics, 5th ed. St. Louis: Mosby c2016. Part III: Laboratory Procedures, Chapter 26 Resin Bonded Fixed Dental Prostheses; p Rosenstiel S, Land M, Fujimoto J. Contemporary Fixed Prosthodontics, 5th ed. St. Louis: Mosby c2016. Part III: Laboratory Procedures, Chapter 21 Retainers for Partial Removable Dental Prostheses; p American College of Prosthodontists. Parameters of Care for the Specialty of Prosthodontics. Partial Edentulism Parameter; J Prosthodontia, 2005 Dec. 14 (4 Suppl 1): Smith B, Howe L. Planning and Making Crowns and Bridges, 4th ed. Boca Raton: CRC Press c2013. Chapter 7, Indications for Bridges Compared with Partial Dentures and Implant Supported Prostheses; p Nesbit S, Kanjirath P, Stefanac S. Treatment Planning for Dentistry, 2nd ed. St. Louis: Mosby c2007. Chapter 8, replacing Missing Teeth: pgs American Dental Association Glossary of Clinical and Administrative Terms: (Accessed February 1, 2016) 11. Rosenstiel S, Land M, Fujimoto J. Contemporary Fixed Prosthodontics, 5th ed. St. Louis: Mosby c2016. Part 1: Planning and Preparation, Chapter 3 Treatment Planning: Pgs Government Agency, Medical Society, and Other Authoritative Publications: History Revision History Version Date Nature of Change SME initial 12/20/16 creation M Kahn G Koumaras Revision 2/8/17 General verbiage Rosen Revision 2/6/18 Appropriateness/medical necessity, Criteria, Codes, discussion, Definitions M Kahn Federal and State law, as well as contract language, and Dental Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Clinical Policy Committee are available for general adoption by plans or lines of business for consistent review of the medical or dental necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to implement a particular Clinical

7 UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan s or line of business s members may instead use the clinical guideline for provider education and/or to review the medical or dental necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical or dental necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. Current Procedural Terminology - CPT 2017 Professional Edition American Medical Association. All rights reserved. Current Dental Terminology - CDT 2018 American Dental Association. All rights reserved. ICD-10-CM 2017: The Complete Official Codebook. All rights reserved.