Crowns, bridges, and buildups

Carol Tekavec, RDH

Most insurance carriers reimburse patients for anterior or bicuspid porcelain/ceramic or resin crowns with no "downcoding" (substituting a lesser-paid code) or "downgrading" (substituting a base metal for a noble metal). Molar teeth may be considered ineligible for "tooth-colored" crowns if the patient's contract specifies that no cosmetic procedures are covered. When in doubt, do a predetermination of benefits on a patient's crowns.

When sending in for a predetermination estimate or claim payment, include radiographs demonstrating four or more surfaces of decay and/or any fractures. An intraoral photo also can speed coverage. A brief narrative describing special problems such as recurrent decay, broken cusps with details of which cusps are involved, posterior endodontic treatment, and/or large fractures on existing restorations may be helpful. If the crown is needed for a cracked tooth, describe where the crack is, indicate if the tooth is painful, and include a photo.

Defective crowns must have been in place for five-to-seven years to be eligible for payment on replacement under many contracts. When predetermining the new crown, include the date of the original crown placement with a narrative indicating the reason a new crown is needed. For example: "No. 30 full-cast, high-noble metal crown placed December 1992. Recurrent decay on MF margin." Including perio charting with the predetermination form to document adequate bone support also is helpful for both individual crowns and/or bridge abutments.

The timing for crown reimbursement may vary according to the carrier's contract with the employer. Many carriers consider the cementation date as the "procedure date." Some carriers consider the prep/impression date to be the "procedure date," and will require that a dentist notify the carrier if a crown is not cemented as planned. A few carriers are requiring both the prep and cementation dates for benefits, presumably to confirm patient eligibility at both times of service. Many insurers will not provide benefits for crowns placed on children under 12.

Code D2950, Core Buildup, Including any Pins, applies to building up the anatomical crown with any type of material, with or without any number of pins. A crown is placed and coded separately, either at the same time or at a later date. Many carriers refuse to reimburse patients for core-buildups under any circumstances, except previous endodontic treatment. Those that do provide benefits require that the remaining anatomical-crown tooth structure be described in a narrative as less than 50 percent and inadequate to provide proper crown retention. Most insurers will not cover a buildup that is placed to remove undercuts. Radiographs are essential for documentation.

As for bridges (now termed fixed-partial dentures by the ADA), many carriers will not cover retainer (abutment) teeth unless they are decayed, fractured, have broken cusps, or have undergone endodontic treatment. Existing, defective abutment crowns usually must have been in place for five-to-seven years to be eligible for replacement. Include the date when the original abutment was placed, along with the reason why a new one is needed. For example, "No. 3 full-cast, high-noble metal crown placed January 1992. Recurrent decay on DF margin."

Fixed bridges typically are only a benefit for patients over 16. Most carriers also will not cover replacement of congenitally-missing teeth. Implants are not a benefit of many plans; however, some plans will allow a benefit for bridges placed on an implant. A predetermination of benefits is recommended when applying for benefits.

Repairs on bridges may be covered if it is likely that they will extend the life of the bridge. Benefits typically are half of the carrier allowance for a replacement.