How To Avoid Claim Denials for Crowns

To avoid claim denials for crowns, it's essential to understand the documentation and criteria required for coverage. The best way to ensure a tooth qualifies for a crown benefit is by submitting a pre-treatment estimate to understand how insurance will cover each procedure in the treatment plan.

However, claim denials for crowns may occur for various reasons, including incorrect documentation or the condition of the tooth or gums. This guide will help you brush up on tips and best practices for submitting claims for a crown, including common reasons for denials. Before submitting a claim, ask yourself the below questions to ensure your claim meets Delta Dental's requirements and policies from the start.

Do You Have Appropriate Pre-Operative Periapical Radiographs?

To submit claims for a crown, you’ll need a pre-operative periapical radiograph to demonstrate the overall health and disease state of the tooth. The radiograph needs to have been taken within one year of the crown prep procedure. Be sure to include periapical radiographic images showing both the apex and clinical crown, as the teeth must be evaluated for periapical pathology. Bitewing radiographs may also help support the claim.

The radiograph must show sufficient tooth loss due to caries or fracture to justify the crown benefit.

Additionally, if your office takes intra-oral photographs, include them alongside the radiographs, but not in place of the intra-oral photos. Intra-oral photos often help demonstrate the need for a crown benefit. Don't wait for a denial to send these - submit them with the initial claim to avoid delays.

Understanding Claim Denials: X-rays

A claim for crowns on tooth #8 and #9 was denied because the radiographs failed to show the entire crown and were of poor quality. Pre-operative radiographs must clearly show the apex and the entire crown. Pro tip: Do not send mid-treatment radiographs or mid-treatment intra-oral photographs of the prepped tooth. Only diagnostic quality pre-operative radiographs and intra-oral photos will be used to determine if the tooth qualifies for a crown benefit.

Most Common Crown Denial Codes Due To Inadequate X-Rays

The reference codes most often associated with crown denials due to X-ray requirements include:

• 186: Benefit determination requires diagnostic pre-operative periapical and bitewing x-ray/radiograph(s) - mid-treatment and post-treatment radiographs are not considered in benefit determination. Please resubmit with the required documentation.
• 193: Benefit determination cannot be made with the x-rays/radiographs received.

Have I Met the Crown Requirements for an Anterior or Posterior Tooth?

The below guidelines must be met in order to determine if the tooth qualifies for the crown benefit.

The general crown guidelines for anterior teeth include:

• Extensive loss of tooth structure due to caries or traumatic fracture.
• Existing restorations need replacement due to caries, fractures, or missing tooth structure.
• At least half of the incisal angle needs replacement due to decay or fracture.
• Endodontically treated teeth with only an access to restore may not be sufficient for a crown benefit. When in doubt, submit a pre-treatment estimate.

The general crown guidelines for posterior teeth include:

• Extensive loss of tooth structure due to caries or traumatic fracture.
• Existing restorations need replacement due to caries, fractures, or missing tooth structure.
• The tooth is endodontically treated.
• There is evidence of a cuspal fracture.

Understanding Claim Denials: Inadequate Criteria

A claim for a crown on tooth #3 was denied because the pre-operative radiograph didn't show significant loss of tooth structure, existing large restorations that are failing, or a fracture. An intra-oral photograph could have supported this claim to avoid a denial.

In this next example, the pre-operative radiographic image for tooth #30 shows more than 50% loss of tooth structure due to existing large restoration but no indication of recurrent caries or fracture.

Most common crown reference codes for inadequate criteria:

• 166: Based on review of the submitted information by a licensed dental consultant and the terms of the member's policy, this procedure does not meet clinical criteria for payment in the absence of tooth loss by dental decay to the extent that the tooth cannot be restored with a more conservative procedure.
• 33: Please refer to Exclusion #6 of the member's benefit handbook which states "No benefits shall be payable for services not necessary or not consistent with the diagnosis or treatment of a dental condition are not covered benefits, as determined by the dental plan administrator.”

Is the Structural Damage Caused by Factors Outside of Wear and Abrasion?

Full crowns placed to repair lesions due to factors such as wear, attrition, abrasion, erosion, or abfraction aren’t covered under most plans. The tooth must show structural loss from decay, large failing restorations, or fracture not caused by these factors.

Understanding Claims Denials: Wear and Abrasion

In the following example, the claim was submitted for crowns on teeth #8 and #9. However, pre-operative radiographic images show incisal wear. Restorative procedures to repair lesions due to wear, attrition, abrasion, erosion, and abfraction aren’t typically covered under the benefit plan.

Most common crown denial code related to wear and abrasion:

• 41: Replacing tooth structure lost due to attrition/wear is not a covered benefit under the member's dental plan.

Does Periodontal Health Support Crown Placement?

You must consider the periodontal health of a tooth before placing a crown. Teeth with uncontrolled or untreated periodontal disease typically have a poor prognosis and are not considered for full crown coverage. For teeth with periodontal involvement, you’ll need to provide documentation of the current periodontal status and history of definitive treatment.

Understanding Claims Denials: Periodontal Disease

This example is from a claim for a crown on tooth #20. The claim was denied because pre-operative radiographic image depicted excessive bone loss due to periodontal disease.

Most common crown denial code related to periodontal disease:

• 54: Documentation submitted does not support payment for this procedure under the member's dental plan due to a guarded, questionable, or poor prognosis.

Has Endodontic Disease Been Appropriately Treated?

You must consider the status of an endodontically treated tooth and submit pre- and post-operative periapical radiographs for endodontically treated teeth.

Understanding Claim Denials: Endodontic Disease

The following radiograph was submitted with a claim for a crown on tooth #13. Because the pre-operative radiographic image shows untreated periapical pathosis, the claim was denied.

In this next example, the pre-operative radiographic image, submitted with a claim for a crown on tooth #19, shows unresolved periapical pathology.

This example is for a crown on tooth #13, but the pre-operative radiographic image shows a poor or short fill of the existing root canal. The material used to fill the root canal does not seal the root.

The following example was submitted with a claim for a crown on tooth #18. However, the pre-operative radiographic image was taken to measure the working length and doesn’t show the completed root canal. This radiograph may be submitted as a pre-operative radiograph, but it doesn’t qualify as a final endodontic film.

In comparison, the following radiographic images correctly depict an acceptable pre-operative periapical x-ray and post-operative x-ray of completed root canal therapy on tooth #19.

Most common crown denial codes related to unresolved endodontic disease

The codes most often associated with crown denials due to untreated or unresolved periapical pathology and poorly filled root canals are:

• 153: When radiographs/x-rays indicate an incompletely filled canal space or unresolved periapical pathology, root canal therapy is subject to a contractual benefit limitation under the member's dental plan. Payment will not be made for this procedure.

Best Practices

To expedite processing and ensure coverage, review all criteria and submit dated radiographs, intra-oral photographs, and any supporting documentation with your claim, keeping the above requirements and best practices in mind.

Additionally, consider submitting the progress notes associated with the procedure to help relay the circumstances related to the overall health and disease state of the tooth. While narratives are helpful, using templates that repeat across claims won't help clinicians assess the need for crown benefits.

For more information, please refer to the 2024 Dentist Handbook, available in the Delta Dental of Illinois Dentist Connection, under “Forms” in the “Resources” tab, to see what documentation and clinical information is needed for specific procedure codes. You can also refer to specific procedure codes in the handbook for more details and the description of procedures.

The 2025 Dentist Handbook will be available early January in the Dentist Connection To register for the Dentist Connection, view our guide.

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