Pre-fabricated Crown Benefits and Criteria

Effective for dates of service on or after May 1, 2017, there is no limitation to the number of pre-fabricated crowns that may be placed on a patient per day. This change aligns the South Carolina Department of Health and Human Services (SCDHHS) policy with the provisions of the South Carolina Dental Sedation Act of 2014, which allows administration of sedation or anesthesia, or both, in a dentist’s office.

The revised benefits apply to all the pre-fabricated crowns with codes D2929, D2930, D2931, D2932 and D2934, currently covered under the South Carolina State Medicaid Plan as described below:

The SCDHHS is also revising the criteria for placement of a pre-fabricated crown. The criteria follows the American Academy of Pediatric Dentistry (AAPD) Clinical Practice Guidelines on restorative dentistry. The revised criteria is as follows:

Pre-Fabricated Crown Criteria

(Includes all pre-fabricated crowns: stainless steel/ esthetic coated stainless steel, resin and porcelain/ceramic.)

Placement of a pre-fabricated crown is allowed once per 36 months per patient per tooth without prior authorization. No other restoration on that tooth is compensable during that period of time. Any additional placements outside of policy will require prior authorization.

Documentation and clinical criteria for placement of pre-fabricated crowns:

Documentation in the patient's records must include the following:

1. A detailed narrative demonstrating medical necessity; AND
2. Appropriate pre-treatment diagnostic images such as:
   1. Radiographs (bitewings, periapicals or panorex) that clearly show the affected tooth/ teeth with decay or trauma, and the adjacent and opposing teeth; OR
   2. Intraoral photographs, if technology is available in provider's office, may be submitted in the absence of radiographs; OR
   3. A narrative documenting why neither radiographs or intraoral photographs were able to be obtained; AND
3. Documentation in support of the following clinical criteria:
   1. Primary teeth (anterior and posterior)
      1. Tooth is expected to have more than 12 months of life prior to exfoliation, based on the child's eruption pattern; AND
      2. Tooth needs an extensive restoration when other restorative materials have a poor prognosis and the restoration is due to any of the following:
         • substantial decay or trauma;
         • cervical decalcification and/or developmental defects;
         • following pulpal therapy
   2. Permanent teeth (anterior, bicuspid, molar)
      1. Tooth needs an extensive restoration when other restorative materials have a poor prognosis and the restoration is due to any of the following:
         • substantial decay or trauma;
         • cervical decalcification and/or developmental defects;
         • following pulpal therapy

It is the provider's responsibility to use clinical and professional judgment when planning extensive treatment and multiple crown placement, evaluating the patient's need, risk for developing tooth decay, health history and their physical and mental ability to support the extensive treatment. A pre-fabricated crown DOES NOT meet the clinical criteria and will not be allowed for reimbursement if:

1. Tooth has subosseous and/or furcation caries;
2. Tooth has advanced periodontal disease;
3. PRIMARY tooth root is surrounded by severe pathologic destruction of bone;
4. PERMANENT tooth apex is surrounded by untreated pathologic destruction of bone;
5. Crown is being planned to alter vertical dimension;
6. Crown is used as a temporizing treatment while a permanent restoration is being fabricated

Please refer any questions or concerns regarding the changes to pre-fabricated crown benefits and criteria to the Provider Service Center at (888) 289-0709. Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.