Coverage Decision for Core Buildup and Crown Following Accidental Dental Trauma
This service should be APPROVED as a covered benefit under the member's certificate, with the core buildup (D2950) and crown (D2740) falling under the accidental injury dental coverage provision, NOT subject to the $1,000 dental implant maximum.
Rationale for Coverage Approval
Certificate Language Supports Coverage
The member's certificate explicitly covers "crowns or caps for broken teeth instead of extraction and replacement" when Prior Authorization is obtained before the service is performed, which has been appropriately requested in this case. The certificate states on pages 40-41 under "Extraction and Replacement of Teeth Due to Injury" that crowns may be considered as an alternative to extraction with prior authorization.
- The injury occurred on 10/25/25 when the member ran into a clear door while shopping, breaking tooth #10 (top left lateral incisor)
- This constitutes a clear accidental injury to a sound natural tooth, meeting the certificate's definition of covered trauma
- The temporary filling was placed on 10/27/25, and prior authorization is being appropriately sought before definitive treatment
The $1,000 Maximum Does NOT Apply
The $1,000 maximum payment limitation specifically applies only to "dental implants and associated supplies and services" per the benefit summary and certificate language on pages 40-41.
- A core buildup and crown are NOT dental implants
- These are restorative procedures to repair the existing natural tooth structure
- The certificate covers "initial repair of accidental injury to sound natural teeth" under the benefit summary
- The $1,000 cap is explicitly limited to implant-related services only
Clinical Appropriateness
The dental provider's recommendation for full coverage restoration (crown with core buildup) is clinically appropriate for this anterior tooth fracture. While the provided clinical guidelines focus primarily on pediatric dental trauma management 1, the principles support crown restoration as a viable treatment option for fractured permanent teeth when pulp vitality can be preserved and adequate tooth structure remains 2.
- Core buildup (D2950) provides structural foundation for crown retention when significant tooth structure is lost 3, 4
- Crown restoration (D2740) protects the remaining tooth structure and provides optimal long-term aesthetic outcome for an anterior tooth 1
- This approach is preferable to extraction and replacement for a young permanent tooth in the aesthetic zone
Coverage Decision Summary
APPROVE: Core buildup (D2950) and crown (D2740) as covered services under the accidental injury dental benefit provision.
Key Points for Authorization:
- Coverage basis: Section 4, Paragraph 20 (Extraction and Replacement of Teeth Due to Injury) - crowns for broken teeth with prior authorization
- Maximum payment: Standard benefit limits apply; the $1,000 dental implant maximum does NOT apply to this case
- Requirements met: Accidental injury documented, prior authorization appropriately requested before service performance
- Exclusions do NOT apply: Section 5.A.12 excludes dental services "except those specifically listed in Section 4.F." - this case falls under the specific coverage provision in Section 4, Paragraph 20
Common Pitfall to Avoid
Do not confuse the general dental service exclusion (Section 5.A.12.a) with the specific accidental injury coverage provision (Section 4, Paragraph 20). The certificate explicitly carves out coverage for crowns on broken teeth due to accidental injury when prior authorization is obtained, which supersedes the general dental exclusion.