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14.2.5.3 Restorations
Restorations do not require prior authorization except for inlay or onlay restorations and crowns (single restorations only) in excess of four in a lifetime, any provider.
Consideration of restoration reimbursement is contingent on compliance with the following limitations:
• Restorations on primary teeth and permanent posterior teeth may be reimbursed on the basis of the surface or surfaces restored and are paid as a total maximum fee per tooth.
•More than one restoration on a single surface is considered a single restoration. A multiple surface restoration cannot be billed as 2 or more separate one-surface restorations.
•The restorations must show definite crossing of the plane of each surface listed for primary and permanent tooth restoration completed to be considered for reimbursement as a multiple surface restoration.
•All reimbursement for tooth restorations include local anesthesia and pulp protection media, where indicated, without additional charges. These services will deny as part of another service if billed separately.
•The CSHCN Services Program reimburses restorations and therapeutic care based on medical necessity. Therapeutic procedures are not reimbursed for preventive purposes.
Amalgam and resin-based composite restorations are limited to clients 1 year of age or older. Gold foil restorations are limited to clients 13 years of age or older.
Inlay or onlay restorations and crowns-single restorations only may be reimbursed at a maximum fee. This fee includes the actual inlay or onlay or crown, any provisional crown, and any preparatory work before the seating of the permanent crown.
Procedure code D2920 is payable to the same CSHCN Services Program dental provider that did the original cementation of the crown.
Crowns-single restoration only procedure codes are limited to CSHCN Services Program clients 13 years of age or older.
Procedure code D2799 is denied as part of the global fee for a crown.
Procedure code D3110 may be reimbursed separately from any final tooth restoration performed on the same tooth on the same date of service by the same provider.
Use the following procedure codes for restoration services:
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Procedure Codes
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Limitations
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Amalgam Restorations
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D2140
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A = NA
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D2150
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A = NA
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D2160
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A = 1 year of age or older
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D2161
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A = 1 year of age or older
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Resin-Based Composite Restorations
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D2330
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A = NA
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D2331
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A = NA
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D2332
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A = 1 year of age or older
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D2335
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A = 1 year of age or older
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D2390
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A = NA
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D2391
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A = NA
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D2392
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A = NA
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D3293
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A = 1 year of age or older
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D2394
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A = 1 year of age or older
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Gold Foil Restorations
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D2410
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A = 13 years of age or older
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D2420
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A = 13 years of age or older
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D2430
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A = 13 years of age or older
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Inlay or Onlay ResLefttorations
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D2510
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A = 13 years of age or older
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D2520
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A = 13 years of age or older
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D2530
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A = 13 years of age or older
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D2542
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A = 13 years of age or older
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D2543
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A = 13 years of age or older
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D2544
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A = 13 years of age or older
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D2610
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A = 13 years of age or older
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D2620
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A = 13 years of age or older
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D2630
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A = 13 years of age or older
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D2642
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A = 13 years of age or older
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D2643
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A = 13 years of age or older
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D2644
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A = 13 years of age or older
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D2650
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A = 13 years of age or older
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D2651
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A = 13 years of age or older
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D2652
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A = 13 years of age or older
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D2662
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A = 13 years of age or older
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D2663
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A = 13 years of age or older
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D2664
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A = 13 years of age or older
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D2710
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A = 13 years of age or older
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D2720
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A = 13 years of age or older
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D2721
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A = 13 years of age or older
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D2722
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A = 13 years of age or older
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D2740
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A = 13 years of age or older
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D2750
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A = 13 years of age or older
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D2751
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A = 13 years of age or older
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D2752
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A = 13 years of age or older
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D2780
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A = 13 years of age or older
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D2781
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A = 13 years of age or older
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D2782
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A = 13 years of age or older
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D2783
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A = 13 years of age or older
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D2790
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A = 13 years of age or older
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D2791
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A = 13 years of age or older
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D2792
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A = 13 years of age or older
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D2794
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A = 13 years of age or older
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D2910
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A = 13 years of age or older
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D2915
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A = 6 years of age or older
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D2920
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A = 1 year of age or older, payable to the same provider that performed the original crown cementation
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D2930
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A = NA
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D2931
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A = 6 years of age or older
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D2932
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A = 1 year of age or older
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D2933
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A = NA
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D2934
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A = NA
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D2940
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A = NA
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D2950
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A = 6 years of age or older
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D2951
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A = 6 years of age or older
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D2952
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A = 13 years of age or older; procedure code D3110 may not be reimbursed with procedure
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D2953
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A = 13 years of age or older; procedure code D3110 may not be reimbursed with procedure
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D2954
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A = 13 years of age or older; procedure code D3110 may not be reimbursed with procedure
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D2955
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A = 4 years of age or older; procedure code D3110 may not be reimbursed with procedure
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D2957
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A = 13 years of age or older; procedure code D3110 may not be reimbursed with procedure
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D2960
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A = 13 years of age or older
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D2961
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A = 13 years of age or older
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D2962
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A = 13 years of age or older
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D2970
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A = 6 years of age or older, procedure code D2970 may be reimbursed once per lifetime for each tooth, any provider
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D2971
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A = 13 years of age or older, limited to four services per lifetime for each tooth by any provider
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D2980
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A = 1 year of age or older; procedure code D3110 may not be reimbursed with procedure
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D2999
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A = 1 year of age or older; procedure code D3110 may not be reimbursed with procedure
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