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Medical Policy

Policy Num:     13.001.001
Policy Name:    Restorative Single Crowns, Inlays and Onlays
Policy ID:          [13.001.001]  [Ar / L / M+ / P+]  [0.00.00]

Last Review:     October 26, 2023
Next Review:     Policy Archived

ARCHIVED
 

Related Policies: None

Restorative Single Crowns, Inlays and Onlays

Summary

A crown, inlay or onlay is the prosthetic construction that is placed fixed in a previously prepared tooth whose objective is to cover the coronal part of the tooth when a pathology or accident occurs such as, and not limited to, dental caries that destroy great part of the tooth, fractures of cusps or endodontics treated tooth. The reason for the crown, inlay or onlay is to protect and restore the anatomy of the affected tooth. These restorations are often made of gold, different alliations of metals/porcelain or porcelain/ceramic.

Objective

Protect and restore the anatomy of the affected tooth, to bring it to a normal masticatory function.

Policy Statements

Single Crowns, inlays or onlays require predetermination and must be accompanied by periapical radiographic images with diagnostic value and a narrative or report informing the clinical and radiographic findings. These procedures are subject to the corresponding coinsurance

Policy Guidelines

      1.  To consider a predetermination request for single crowns, teeth must comply with the following requirements:

a.   To be periodontal healthy and free from lesions of endodontic origin (if they have been treated recently for some of these conditions, it must include a report).

b. Be asymptomatic, except in cases of cracked tooth syndrome, where after exhausting all alternatives it is determined that the solution is the construction of a crown (you must send a detailed report indicating that other alternatives were used before taking the decision to make the crown).

c.  That the tooth crown manifests structural weakness in such degree that it is not possible to restore with intra-coronal fillings.

d.   In the case of a tooth that is going to have a root canal treatment, the procedure, must be completed before requesting the crown predetermination and a postoperative radiographic image must be sent.

2.  Permanent crowns on primary teeth will not be considered for payment.

  3.  Crowns will not be considered for payment for; splinting teeth, neither for cosmetic reasons suchas and not limited to, the reconstruction of peg laterals teeth, the conversion of canines to lateral in cases of congenital agenesis, diastema closures and anterior teeth with root canal treatment that do not demonstrate structural weakness.

 4. The fee of the construction of a crown includes all materials, procedures, and techniques such as, and not limited to, temporary, removal of prior crowns, bases, etc.

 5.   A crown predetermined by Triple-S Salud can only be billed after it has been cemented. In other words, the billing date must be the same date of cementation.

 6.   Triple-S Salud will not consider for payment crowns with preventive purposes, in order to avoid possible fractures or change in color on teeth that have been properly restored.

 7.  Preparation of crowns to correct vertical dimension or the occlusal plane is a service not covered for payment.

 8.  Replacement of crowns after 5 years will be considered for payment with a proper justification.

 9.  The provisional crown (D2799) in permanent teeth is limited to payment to one per life per tooth and it is required that the necessity is documented in the file. If a permanent crown is done within 6 months, the fee of the temporary crown will be considered as included in the fee of the permanent crown.

10.   For rules and limitations of crown on implants refer to the section on “implant Services”.

Benefit Application

BlueCard/National Account Issues - N/A

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

A crown, inlay or onlay is the prosthetic construction that is placed fixed in a previously prepared tooth whose objective is to cover the coronal part of the tooth when a pathology or accident occurs such as, and not limited to, dental caries that destroy great part of the tooth, fractures of cusps or endodontics treated tooth.

Definition of interest;

Crown

A prosthesis that is used to restore a tooth to proper occlusion, contact, and contour. It can be as a single restoration or as an abutment for a fixed prosthesis.

Inlay

A cast restoration made to fit a tooth cavity preparation and the cemented into place.

Onlay

A cast restoration that covers the entire incisal or occlusal surface of the tooth.

Regulatory Status

N/A

Rationale

Protect and restore the anatomy of the affected tooth destroyed by dental caries / trauma and tooth with root Canals treatment and bring the tooth to a normal masticatory function.

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American];LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflectiveof and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g.,women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Population Reference No. 1 

Tooth with great part of its structure missing caused by cavities or trauma and tooth with root canal treatments restoring it with; (single crown, inlays or onlays)

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

 1.       Participating Odontologist Manual 2023, Rules and Limitations for Complete and Partial Dentures.

 2.       Participating Prosthodontist Manual 2023, Rules and Limitations for Complete and Partial Dentures.

 3.       Insured’s certificate of coverage, exclusions of the dental coverage.

a. Every service not included as covered service in the description of coverage.

b. Every dental service that is rendered with purely cosmetic purposes.

4.  Richard L. Gorwood, Dentistry and Dental Insurance Claim, 1993, Prosthodontics   Removable and Fixed, Removable Prosthodontics, pages 117-128.

   5. Infam Ahmad, Manual de Consulta Rápida en Prostodoncia, 2013, Sección 16; Prótesis Removible. (Prosthodontics Quick Consultation Manual, 2013 Section 16, Removable Prosthesis)

Codes

Appplicable Modifiers

N/A

Policy History