Prefabricated porcelain or ceramic crown – permanent tooth (049)

Number: 049
(New)

Subject: Prefabricated porcelain/ceramic crown – permanent tooth

Reviewed: September 10, 2020*

Important note

This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).

Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in this Bulletin. The discussion, analysis, conclusions and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna’s opinion and are made without any intent to defame.

Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.

Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.

The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (for example, will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members.

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Policy

Prefabricated crowns are considered to be provisional (temporary) restorations when performed on permanent teeth.  Provisional restorations are excluded from coverage in most dental plans.

Background

Since there exists a CDT code for preformed ceramic/zirconia crowns for primary teeth but not for permanent teeth, a new code for preformed ceramic/zirconia crowns for permanent teeth is being introduced by the American Dental Association in CDT 2021.  In the American Dental Association’s official documentation for the CDT 2021 code request, it is stated that “Preformed Zirconia crowns are no different than preformed stainless steel crowns in their use and purpose” and “These crowns can be an excellent long-term temporary solution.”

According to a leading manufacturer of stainless steel crowns, “3M ESPE Stainless Steel Crowns are designed to provide long-term coverage of primary molar teeth and long-term provisional coverage of permanent molar teeth.”¹

When a prefabricated porcelain/ceramic crown is performed on a permanent tooth, we consider it to be a provisional restoration.

Code²

D2928 - prefabricated porcelain/ceramic crown – permanent tooth*

Review dates

Original policy: September 10, 2020, effective January 1, 2021

The above policy is based on the following references:

¹A comprehensive guide to achieving the best results with 3M™ ESPE™ Prefabricated Crowns (PDF). Accessed September 2020. 

²American Dental Association. CDT 2019 Dental Procedure Codes.*

*Copyright 2020 American Dental Association. All rights reserved. Effective 01-01-2021

Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.