Health Evidence Review Commission's Oral Health …€¦ · 22/9/2015 · Update on restoration of benefits for adults ... PROSTHESIS FAILURE) Treatment: REMOVABLE ... PRIMARY TOOTH

Health Evidence Review

Commission's

Oral Health Advisory Panel

September 22, 2015

8:00 AM

Clackamas Community College

Wilsonville Training Center, Room 210

29373 SW Town Center Loop E, Wilsonville, Oregon,

97070

Section 1.0

Call to Order

AGENDA ORAL HEALTH ADVISORY PANEL (OHAP)

September 22, 2015 Wilsonville Training Center, Room 210

8:00 – 10:00 am

(All agenda items are subject to change and times listed are approximate)

# Time Item Presenter

1 8:00 AM Call to Order & Introductions Bruce Austin

2 8:05 AM Purpose of Meeting Ariel Smits

3 8:10 AM

1. 2016 CDT code placement

2. Placement of CDT codes on the Prioritized List and on another list

3. Denture code placement review

4. Possible guideline for crowns

Ariel Smits

4 9:15 AM Medicaid dental access issues Bruce Austin

5 9:30 AM

Update on restoration of benefits for adults

-dentures

-crowns

-interval for scaling and root planing

Bruce Austin

6 9:45 AM Dental metrics? ?

7 9:55 AM Public Comment

8 10:00 AM Adjournment Bruce Austin

OHAP Draft Highlights 10-15-2014 Page 1

Highlights

Oral Health Advisory Panel Conference Call hosted at:

General Services Building, Mary’s Peak Converence Room 1225 Ferry Street, Salem, Oregon

10/15/2014 11:00 am - 12:00pm

Members Present:James Tyack, DMD, Chair; Deborah Weston; Patricia Parker, DMD; Cedric Hayden, DMD. Staff Present: Darren Coffman; Ariel Smits, MD, MPH; Denise Taray. Also Attending: Bruce Austin, DMD, Capitol Dental Care; Laura McKeane, All Care.

Review of New CDT Codes for 2015 The following recommendations were suggested for staff to present to the Value-based Benefits Subcommittee at their November 13, 2014 meeting:

CDT Code

Code description Proposed Placement Comments

D0171 re-evaluation – post-operative office visit Excluded Service should be bundled into the original treatment code

D0351 3D PHOTOGRAPHIC IMAGE-This procedure is for dental or maxillofacial diagnostic purpose-es. Not applicable for a CAD-CAM procedure

Excluded Experimental

D1353 SEALANT REPAIR-PER TOOTH 57 PREVENTIVE DENTAL SERVICES D1351 Sealant is on line 57. Rule limits sealants to every 5 yrs unless they fail, then sealant can be redone. Monitor use to ensure not abused.


CDT Code


D6110 implant /abutment supported removable denture for edentulous arch – maxillary

627 DENTAL CONDITIONS (EG. MISSING TEETH) Treatment: IMPLANTS

D6111 implant /abutment supported removable denture for edentulous arch – mandibular


D6112 implant /abutment supported removable denture for partially edentulous arch – maxillary


D6113 implant /abutment supported removable denture for partially edentulous arch – mandibular


D6114 implant /abutment supported fixed denture for edentulous arch – maxillary


D6115 implant /abutment supported fixed denture for edentulous arch – mandibular


D6116 implant /abutment supported fixed denture for partially edentulous arch – maxillary


D6117 implant /abutment supported fixed denture for partially edentulous arch – mandibular


D6549 RESIN RETAINER--FOR RESIN BONDED FIXED PROSTHESIS

609 DENTAL CONDITIONS (EG. MISSING TEETH) Treatment: COMPLEX PROSTHODONTICS

D9931 Cleaning and inspection of a removable appliance. This procedure does not include any required adjustments

457 DENTAL CONDITIONS (EG. MISSING TEETH, PROSTHESIS FAILURE) Treatment: REMOVABLE PROSTHODONTICS

Includes ultrasonic cleaning of dentures. DMAP to create rule to limit frequency to once per year and can not be billed with a prophylactic cleaning.

D9936 missed appointment Excluded Specifically excluded in OAR from being billed

D9987 Cancelled appointment Excluded Specifically excluded in OAR from being billed


CDT Code


D9219 evaluation for deep sedation or general anesthesia

Exempt Anesthesia codes are all Exempt

Denture Guideline

The members on the conference call suggested that staff recommend to VbBS that the denture guideline (Guideline Note 62) be eliminated. It is not currently in line with MAP administrative rules and adjusting it so that they align would only result in duplication.

Section 2.0

2016 CDT codes

2016 CDT Code Placement

CDT

CodeCode Description Suggested Placement Comments

D0251 extra-oral posterior dental radiographic image Diagnostic List

D0422collection and preparation of genetic sample

material for laboratory analysis and report

Services

Recommended for Non-

Coverage Table

Similar code D0421 (GENETIC TEST FOR SUSCEPTIBILITY TO ORAL

DISEASES) is on the SRNC table

D0423genetic test for susceptibility to diseases –

specimen analysis

Services


Coverage Table

See D0422

D1354 interim caries arresting medicament applicationNeeds further discussion

D4283

autogenous connective tissue graft procedure

(including donor and recipient surgical sites) –

each additional contiguous tooth, implant or

edentulous tooth position in same graft site

496 DENTAL

CONDITIONS (EG.

PERIODONTAL

DISEASE)

D4273 (SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURES, PER

TOOTH) is currently on line 496, and this is code is meant to be used in

conjunction with D4273.

D4285

non-autogenous connective tissue graft

procedure (including recipient surgical site and

donor material) – each additional contiguous

tooth, implant or edentulous tooth position in

same graft site

496 DENTAL

CONDITIONS (EG.

PERIODONTAL

DISEASE)

D4275 (SOFT TISSUE ALLOGRAFT) and D4276 (COMBINED CONNECTIVE

TISSUE AND DOUBLE PEDICLE GRAFT, PER TOOTH) are currently listed on

line 496 and on the SRNC. This is code is meant to be used in conjunction with

D4275.

D5221

immediate maxillary partial denture – resin base

(including any conventional clasps, rests and

teeth)

594 DENTAL

CONDITIONS (EG.

CARIES, FRACTURED

TOOTH)

Most partial dentures are on line 594. There is some partial dental coverage

[e.g. D5130 IMMEDIATE DENTURE - MAXILLARY or D5211 (UPPER PARTIAL-

RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND

TEETH))] on line 457 DENTAL CONDITIONS (EG. MISSING TEETH,

PROSTHESIS FAILURE).

D5222

immediate mandibular partial denture – resin

base (including any conventional clasps, rests

and teeth)

594 DENTAL

CONDITIONS (EG.

CARIES, FRACTURED

TOOTH)

See D5221 above

D5223

immediate maxillary partial denture – cast metal

framework with resin denture bases (including

any conventional clasps, rests and teeth)

594 DENTAL

CONDITIONS (EG.

CARIES, FRACTURED

TOOTH)

D5213 (MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH

RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS,

RESTS AND TEETH)) is on line 594.

D5224

immediate mandibular partial denture – cast

metal framework with resin denture bases

(including any conventional clasps, rests and

teeth)

594 DENTAL

CONDITIONS (EG.

CARIES, FRACTURED

TOOTH)

D5213 (MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK

WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL

CLASPS,RESTS AND TEETH)) is on line 594

Page 1 of 2

2016 CDT Code Placement

CDT

CodeCode Description Suggested Placement Comments

D7881 occlusal orthotic device adjustment 552 TMJ DISORDER D7880 (OCCLUSAL ORTHOTIC APPLIANCE) is on line 552

D8681 removable orthodontic retainer adjustment

47 CLEFT PALATE

WITH AIRWAY

OBSTRUCTION

305 CLEFT PALATE

AND/OR CLEFT LIP

621 DENTAL

CONDITIONS (EG.

MALOCCLUSION)

Similar orthodontic retainer codes D8680-D8693 are on lines 47,305,621

D9223deep sedation/general anesthesia – each 15

minute incrementAncillary

This code replaces D9220 (initial 30 min) and D9221 (each additional 15 min)

which are listed as Exempt but should be Ancillary.

***Why are all the dental anesthesia codes (D9220-D9248) Exempt and not

Ancillary?***

D9243intravenous moderate (conscious)

sedation/analgesia – each 15 minute incrementAncillary

This code replaces D9241 (initial 30 min) and D9242 (each additional 15 min).

See D9223 above

D9932cleaning and inspection of removable complete

denture, maxillary

Services


Coverage Table

D9931 (Cleaning and inspection of a removable appliance) is on the SRNC as of

October 1, 2015. D9932-D9935 will replace D9931.

D9933cleaning and inspection of removable complete

denture, mandibular

Services


Coverage Table

See D9932

D9934cleaning and inspection of removable partial

denture, maxillary

Services


Coverage Table

See D9932

D9935cleaning and inspection of removable partial

denture, mandibular

Services


Coverage Table

See D9932

D9943 occlusal guard adjustment

650 DENTAL

CONDITIONS WHERE

TREATMENT

RESULTS IN

MARGINAL

IMPROVEMENT

D9942 (REPAIR AND/OR RELINE OF OCCLUSAL GUARD) is on line 650 and

SRNC.

Page 2 of 2

CDT Codes on the Prioritized List and on Another List

1

The following codes have two placements in the HERC database and HERC staff would like input on which of the two lists the code actually

belongs. HERC and OHA dental staff have reviewed these codes and recommend the placements shown in the final column based on current

coverage in the OHA system. Highlighted codes would have coverage changes depending on which of the 2 lists is selected. As a note, dental

does not use the Ancillary code, so these placements are obviously errors.

Code Code Description Current Placement Recommended Placement

D0350 2D ORAL/FACIAL PHOTOGRAPHIC IMAGES OBTAINED INTRAORALLY OR EXTRAORALLY

Diagnostic List 626 DENTAL CONDITIONS (EG. MALOCCLUSION)

626 per 2010 review

D1310 NUTRITIONAL COUNSELING FOR THE CONTROL OF DENTAL DISEASE

Ancillary 57 PREVENTIVE DENTAL SERVICES

57

D2712 CROWN - 3/4 RESIN-BASED COMPOSITE (INDIRECT) Ancillary 473 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH)

473

D2794 CROWN-TITANIUM Ancillary 599 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH)

599

D2915 RECEMENT OR RE-BOND INDIRECTLY FABRICATED OR PREFABRICATED POST AND CORE

Services Recommended for Non-Coverage (SRNC) 270 DENTAL CONDITIONS (TIME SENSITIVE EVENTS)

270

D2934 PREFABRICATED ESTHETIC COATED STAINLESS STEEL CROWN - PRIMARY TOOTH

SRNC 654 DENTAL CONDITIONS WHERE TREATMENT IS CHOSEN PRIMARILY FOR AESTHETIC CONSIDERATIONS

654

D2970 TEMPORARY CROWN (FRACTURED TOOTH) Ancillary 270 DENTAL CONDITIONS (TIME SENSITIVE EVENTS)

270

D2971 ADDITIONAL PROCEDURES TO CONSTRUCT NEW CROWN UNDER EXISTING PARTIAL DENTURE FRAMEWORK

SRNC 599 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH)

599

D5225 MAXILLARY PARTIAL DENTURE - FLEXIBLE BASE SRNC 655 DENTAL CONDITIONS WHERE TREATMENT RESULTS IN MARGINAL IMPROVEMENT

655

D5226 MANDIBULAR PARTIAL DENTURE - FLEXIBLE BASE SRNC 655


2


655 DENTAL CONDITIONS WHERE TREATMENT RESULTS IN MARGINAL IMPROVEMENT

D5670 REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MAXILLARY)

SRNC 457 DENTAL CONDITIONS (EG. MISSING TEETH, PROSTHESIS FAILURE)

457

D5671 REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MANDIBULAR)

SRNC 457 DENTAL CONDITIONS (EG. MISSING TEETH, PROSTHESIS FAILURE)

457

D5811 INTERIM COMPLETE DENTURE (MANDIBULAR) SRNC 599 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH)

599

D6094 ABUTMENT SUPPORTED CROWN - (TITANIUM) SRNC 627 DENTAL CONDITIONS (EG. MISSING TEETH)

627

D6190 RADIOGRAPHIC/SURGICAL IMPLANT INDEX, BY REPORT

SRNC 627 DENTAL CONDITIONS (EG. MISSING TEETH)

627

D6194 ABUTMENT SUPPORTED RETAINER CROWN FOR FPD - (TITANIUM)

SRNC 627 DENTAL CONDITIONS (EG. MISSING TEETH)

627

D6205 PONTIC - INDIRECT RESIN BASED COMPOSITE SRNC 599 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH)

599

D6214 PONTIC - TITANIUM SRNC 599 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH)

599

D6624 INLAY - TITANIUM SRNC 599 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH)

599

D6634 ONLAY - TITANIUM SRNC 599 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH)

599

D6710 CROWN - INDIRECT RESIN BASED COMPOSITE SRNC 599 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH)

599


3


D6794 CROWN - TITANIUM SRNC 599 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH)

599

D6985 PEDIATRIC PARTIAL DENTURE, FIXED SRNC 654 DENTAL CONDITIONS WHERE TREATMENT IS CHOSEN PRIMARILY FOR AESTHETIC CONSIDERATIONS

654

D7261 PRIMARY CLOSURE OF A SINUS PERFORATION SRNC 58 DENTAL CONDITIONS (EG. INFECTION, PAIN, TRAUMA)

58

D7282 MOBILIZATION OF ERUPTED OR MALPOSITIONED TOOTH TO AID ERUPTION

SRNC 626 DENTAL CONDITIONS (EG. MALOCCLUSION)

626

D7283 PLACEMENT OF DEVICE TO FACILITATE ERUPTION OF IMPACTED TOOTH

SRNC 626 DENTAL CONDITIONS (EG. MALOCCLUSION)

626

D7311 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH SPACES, PER

Ancillary 348 DENTAL CONDITIONS (EG. SEVERE CARIES, INFECTION)

348

D7321 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT

Ancillary 348 DENTAL CONDITIONS (EG. SEVERE CARIES, INFECTION)

348

D7560 MAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR FOREIGN BODY

Ancillary 58 DENTAL CONDITIONS (EG. INFECTION, PAIN, TRAUMA)

58

D7950 OSSEOUS, OSTEOPERIOSTEAL, OR CARTILAGE GRAFT OF THE MANDIBLE OR MAXILLA - AUTOGENOUS OR NONAUTOGENOUS, BY REPORT

Ancillary 655 DENTAL CONDITIONS WHERE TREATMENT RESULTS IN MARGINAL IMPROVEMENT

655 per 2010 review

D7953 BONE REPLACEMENT GRAFT FOR RIDGE PRESERVATION - PER SITE

SRNC 655 DENTAL CONDITIONS WHERE TREATMENT RESULTS IN MARGINAL IMPROVEMENT

655

D7963 FRENULOPLASTY SRNC 348 DENTAL CONDITIONS (EG. SEVERE CARIES, INFECTION)

348


4


D7972 SURGICAL REDUCTION OF FIBROUS TUBEROSITY SRNC 655 DENTAL CONDITIONS WHERE TREATMENT RESULTS IN MARGINAL IMPROVEMENT

655

D9942 REPAIR AND/OR RELINE OF OCCLUSAL GUARD SRNC 655 DENTAL CONDITIONS WHERE TREATMENT RESULTS IN MARGINAL IMPROVEMENT

655

Section 3.0

Dental crowns and dentures

Denture Coverage on the Prioritized List

1

Issue: Denture coverage has been added back as an OHP service for adults. HERC staff reviewed current

denture CDT code placement on the Prioritized List and would like this placement reviewed for

appropriateness by the OHAP. The current funding line is 475. Blue=new code

CDT code

Code Description Current Placement Treatment

D5110- D5140

COMPLETE DENTURE, MAXILLARY or MANDIBULAR

457 DENTAL CONDITIONS (EG. MISSING TEETH, PROSTHESIS FAILURE)

REMOVABLE PROSTHODONTICS (E.G. FULL AND PARTIAL DENTURES, RELINES)

D5211-D5212

PARTIAL-RESIN BASE 457

D5213-D5214

PARTIAL DENTURE - CAST METAL

594 DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH)

ADVANCED RESTORATIVE-ELECTIVE

D5221-D5222

immediate partial denture – resin base

594

D5223-D5224

immediate partial denture – cast metal framework with resin denture bases

594

D5225- D5226

PARTIAL DENTURE - FLEXIBLE BASE

650 DENTAL CONDITIONS WHERE TREATMENT RESULTS IN MARGINAL IMPROVEMENT

ELECTIVE DENTAL SERVICES

D5281 REMOVABLE UNILATERAL PARTIAL DENTURE-ONE PIECE CAST METAL

594

D5810-D5811

INTERIM COMPLETE DENTURE

594

D5820-D5821

INTERIM PARTIAL DENTURE 457

D5863-D5866

overdenture—complete or partial

604 DENTAL CONDITIONS (EG. MISSING TEETH)

COMPLEX PROSTHODONTICS (I.E. FIXED BRIDGES, OVERDENTURES)

D6093-D6117

implant /abutment supported removable denture

622 DENTAL CONDITIONS (EG. MISSING TEETH)

IMPLANTS

D6985 PEDIATRIC PARTIAL DENTURE, FIXED

649 DENTAL CONDITIONS WHERE TREATMENT IS CHOSEN PRIMARILY FOR AESTHETIC CONSIDERATIONS

COSMETIC DENTAL SERVICES

Crown Guideline

1

Question: Should a new guideline note be adopted to limit the utilization of crowns? Question source: HERC staff, Bruce Austin DMD Issue: The legislature has added back coverage of crowns for non-pregnant adults. The current coverage of crowns on the Prioritized List has no limitations on use. Currently, CDT codes for crowns are found on two lines, 472 and 622. Line: 472 Condition: DENTAL CONDITIONS (EG. CARIES, FRACTURED TOOTH) (See Guideline Note 91) Treatment: ADVANCED RESTORATIVE (I.E. BASIC CROWNS) HCPCS: D2710,D2712,D2751,D2752

Line: 622 Condition: DENTAL CONDITIONS (EG. MISSING TEETH) Treatment: IMPLANTS (I.E. IMPLANT PLACEMENT AND ASSOCIATED CROWN OR PROSTHESIS) ICD-9: 525.71-525.79 HCPCS: D0393-D0395,D6010-D6194,D6210,D6240,D6245,D6250,D7951,D7952

Current restriction summary: -Stainless Steel Crowns are limited to pregnant adults and to posterior primary or permanent teeth and primary anterior teeth once in a five-year period.

-Porcelain Crowns are covered once in a seven-year period for members ages 16-20 and pregnant women of all ages and require clinical and X-ray information for review. Benefit is available for the following anterior teeth only: 6-11, 22 & 27. Permanent crowns are limited to a total of four crowns in a seven-year period. Rule also requires that rampant caries are arrested, and the client demonstrates a period of oral hygiene before prosthetics are proposed

The specific rules governing crowns prior to the legislative funding increase are listed on the

follow pages.

HERC staff recommendation: 1) Discuss whether HERC should adopt a guideline for crowns or whether restrictions on

crowns are best done through OHA dental rules

Crown Guideline

2

OAR 410-123-1260

(5) RESTORATIVE SERVICES:

(a) Amalgam and resin-based composite restorations, direct:

(A) Resin-based composite crowns on anterior teeth (D2390) are only covered for clients under 21 years of age or who are pregnant;

(B) The Division reimburses posterior composite restorations at the same rate as amalgam restorations;

(C) The Division limits payment for replacement of posterior composite restorations to once every five years;

(D) The Division limits payment of covered restorations to the maximum restoration fee of four surfaces per tooth. Refer to the American Dental Association (ADA) CDT codebook for definitions of restorative procedures;

(E) Providers shall combine and bill multiple surface restorations as one line per tooth using the appropriate code. Providers may not bill multiple surface restorations performed on a single tooth on the same day on separate lines. For example, if tooth #30 has a buccal amalgam and a mesial-occlusal-distal (MOD) amalgam, then bill MOD, B, using code D2161 (four or more surfaces);

(F) The Division may not reimburse for an amalgam or composite restoration and a crown on the same tooth;

(G) Interim therapeutic restoration on primary dentition (D2941) is covered to restore and prevent progression of dental caries. Interim therapeutic restoration is not a definitive restoration.

(H) Reattachment of tooth fragment (D2921) is covered once in the lifetime of a tooth when there is no pulp exposure and no need for endodontic treatment.

(I) The Division reimburses for a surface not more than once in each treatment episode regardless of the number or combination of restorations;

(J) The restoration fee includes payment for occlusal adjustment and polishing of the restoration;

(b) Indirect crowns and related services:

(A) General payment policies:

(i) The fee for the crown includes payment for preparation of the gingival tissue;

(ii) The Division shall cover crowns only when:

(I) There is significant loss of clinical crown and no other restoration will restore function; and

(II) The crown-to-root ratio is 50:50 or better, and the tooth is restorable without other surgical procedures;

(iii) The Division shall cover core buildup (D2950) only when necessary to retain a cast restoration due to extensive loss of tooth structure from caries or a fracture and only when done in conjunction

Crown Guideline

3

with a crown. Less than 50 percent of the tooth structure must be remaining for coverage of the core buildup.

(iv) Reimbursement of retention pins (D2951) is per tooth, not per pin;

(B) The Division shall not cover the following services:

(i) Endodontic therapy alone (with or without a post);

(ii) Aesthetics (cosmetics);

(iii) Crowns in cases of advanced periodontal disease or when a poor crown/root ratio exists for any reason;

(C) The Division shall cover acrylic heat or light cured crowns (D2970 temporary crown, fractured tooth) — allowed only for anterior permanent teeth;

(D) The Division shall cover the following only for clients under 21 years of age or who are pregnant:

(i) Prefabricated plastic crowns (D2932) are allowed only for anterior teeth, permanent or primary;

(ii) Stainless steel crowns (D2930/D2931) are allowed only for anterior primary teeth and posterior permanent or primary teeth;

(iii) Prefabricated stainless steel crowns with resin window (D2933) are allowed only for anterior teeth, permanent or primary;

(iv) Prefabricated post and core in addition to crowns (D2954/D2957);

(v) Permanent crowns (resin-based composite — D2710 and D2712, and porcelain fused to metal (PFM) — D2751 and D2752) as follows:

(I) Limited to teeth numbers 6–11, 22 and 27 only, if dentally appropriate;

(II) Limited to four in a seven-year period. This limitation includes any replacement crowns allowed according to (E)(i) of this rule;

(III) Only for clients at least 16 years of age; and

(IV) Rampant caries are arrested, and the client demonstrates a period of oral hygiene before prosthetics are proposed;

(vi) PFM crowns (D2751 and D2752) shall also meet the following additional criteria:

(I) The dental practitioner has attempted all other dentally appropriate restoration options and documented failure of those options;

(II) Written documentation in the client’s chart indicates that PFM is the only restoration option that will restore function;

(III) The dental practitioner submits radiographs to the Division for review; history, diagnosis, and treatment plan may be requested. (See OAR 410-123-1100 Services Reviewed by the Division);

(IV) The client has documented stable periodontal status with pocket depths within 1–3 millimeters. If PFM crowns are placed with pocket depths of 4 millimeters and over, documentation shall be maintained in the client’s chart of the dentist’s findings supporting stability and why

Crown Guideline

4

the increased pocket depths will not adversely affect expected long-term prognosis;

(V) The crown has a favorable long-term prognosis; and

(VI) If the tooth to be crowned is a clasp/abutment tooth in partial denture, both prognosis for the crown itself and the tooth’s contribution to partial denture shall have favorable expected long-term prognosis;

(E) Crown replacement:

(i) Permanent crown replacement limited to once every seven years;

(ii) All other crown replacement limited to once every five years; and

(iii) The Division may make exceptions to crown replacement limitations due to acute trauma, based on the following factors:

(I) Extent of crown damage;

(II) Extent of damage to other teeth or crowns;

(III) Extent of impaired mastication;

(IV) Tooth is restorable without other surgical procedures; and

(V) If loss of tooth would result in coverage of removable prosthetic;

(F) Crown repair (D2980) is limited to only anterior teeth.

Documents

Health Evidence Review Commission's Oral Health …€¦ · 22/9/2015 · Update on restoration of benefits for adults ... PROSTHESIS FAILURE) Treatment: REMOVABLE ... PRIMARY TOOTH