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 by any provider. Procedure code D2999 requires prior authorization.

Gold foil restoration (procedure codes D2410, D2420, and D2430) and inlay or onlay (procedure codes D2610, D2620, D2630, D2642, D2643, and D2644) require prior authorization with documentation of medical necessity.

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 two 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 may reimburse restorations and therapeutic care based on medical necessity. Therapeutic procedures are not reimbursed for preventive purposes.

Inlay or onlay restorations and crowns–single restorations only may be reimbursed a maximum fee when performed on permanent teeth. This fee includes the actual inlay or onlay or crown, any provisional crown, and any preparatory work before the seating of the permanent crown.

Single restoration only crown procedure codes are limited to CSHCN Services Program clients who are 13 years of age or older.

Procedure code D2799 is denied as part of the global fee for a crown.

Use the following procedure codes for restoration services:

 

Procedure Codes	Limitations
Amalgam Restorations
D2140	A = NA
D2150	A = NA
D2160	A = 1 year of age or older
D2161	A = 1 year of age or older
Resin-Based Composite Restorations
D2330	A = NA
D2331	A = NA
D2332	A = 1 year of age or older
D2335	A = 1 year of age or older
D2390	A = NA
D2391	A = NA
D2392	A = NA
D2393	A = 1 year of age or older
D2394	A = 1 year of age or older
Gold Foil Restorations
D2410	A = 13 years of age or older
D2420	A = 13 years of age or older
D2430	A = 13 years of age or older
Inlay or Onlay Restorations
D2510	A = 13 years of age or older
D2520	A = 13 years of age or older
D2530	A = 13 years of age or older
D2542	A = 13 years of age or older
D2543	A = 13 years of age or older
D2544	A = 13 years of age or older
D2610	A = 13 years of age or older
D2620	A = 13 years of age or older
D2630	A = 13 years of age or older
D2642	A = 13 years of age or older
D2643	A = 13 years of age or older
D2644	A = 13 years of age or older
D2650	A = 13 years of age or older
D2651	A = 13 years of age or older
D2652	A = 13 years of age or older
D2662	A = 13 years of age or older
D2663	A = 13 years of age or older
D2664	A = 13 years of age or older
D2710	A = 13 years of age or older
D2720	A = 13 years of age or older
D2721	A = 13 years of age or older
D2722	A = 13 years of age or older
D2740	A = 13 years of age or older
D2750	A = 13 years of age or older
D2751	A = 13 years of age or older
D2752	A = 13 years of age or older
D2780	A = 13 years of age or older
D2781	A = 13 years of age or older
D2782	A = 13 years of age or older
D2783	A = 13 years of age or older
D2790	A = 13 years of age or older
D2791	A = 13 years of age or older
D2792	A = 13 years of age or older
D2794	A = 13 years of age or older
D2910	A = 13 years of age or older
D2915	A = 6 years of age or older
D2920	A = 1 year of age or older, payable to any CSHCN Services Program dental provider, including the same provider that performed the original crown cementation
D2930	A = NA
D2931	A = 6 years of age or older
D2932	A = 1 year of age or older
D2933	A = NA
D2934	A = NA
D2940	A = NA
D2950	A = 6 years of age or older
D2951	A = 6 years of age or older
D2952	A = 13 years of age or older; procedure codes D3110 and D3120 may not be reimbursed when billed with procedure code D2952 for the same tooth, for the same date of service, by the same provider
D2953	A = 13 years of age or older; procedure codes D3110 and D3120 may not be reimbursed when billed with procedure code D2953 for the same tooth, for the same date of service, by the same provider
D2954	A = 13 years of age or older; procedure codes D3110 and D3120 may not be reimbursed when billed with procedure code D2954 for the same tooth, for the same date of service, by the same provider
D2955	A = 4 years of age or older; procedure codes D3110 and D3120 may not be reimbursed when billed with procedure code D2955 for the same tooth, for the same date of service, by the same provider
D2957	A = 13 years of age or older; procedure codes D3110 and D3120 may not be reimbursed when billed with procedure code D2957 for the same tooth, for the same date of service, by the same provider
D2960	A = 13 years of age or older
D2961	A = 13 years of age or older
D2962	A = 13 years of age or older
D2970	A = 6 years of age or older, procedure code D2970 may be reimbursed once per lifetime for each tooth, any provider
D2971	A = 13 years of age or older, limited to four services per lifetime for each tooth by any provider
D2980	A = 1 year of age or older; procedure codes D3110 and D3120 may not be reimbursed when billed with procedure code D2980 for the same tooth, for the same date of service, by the same provider
D2999	A = 1 year of age or older; procedure codes D3110 and D3120 may not be reimbursed when billed with procedure code D2999 for the same tooth, for the same date of service, by the same provider, prior authorization
A = Age limitation