Last March, HPSM Dental updated its dental crown policy. The new policy will require treatment plan review for more than four (4) crowns on any one individual in one calendar year.
If you plan to clinically proceed with more than four crowns (of any material), please send the case for review to [email protected] or call 650-616-1522 as soon as possible to let us know. With the request, please include:
- The American Dental Association (ADA) authorization form
- X-rays, images, narrative, and any other supporting documentation to support medical necessity
- Please also clearly include the prognosis of the tooth/teeth.
If more than four crowns are billed within one calendar year, the fifth crown will automatically be denied without treatment plan review. If this occurs, a retroactive authorization can still be reviewed by HPSM.
To consider more than four (4) crowns and ensure compliance with Medicaid criteria, it is suggested providers clearly outline the following along with acquiring radiographs:
| Criteria | Example |
| Tooth number | Tooth #4 |
| Surfaces and cusps destroyed by caries, or note other etiology | MODBL surfaces destroyed/ undermined due to caries |
| Tooth vitality testing and diagnosis; or if RCT, prognosis of existing RCT | RCT previously completed on 1/4/26 with good prognosis, vitality testing 1/2/26 with periapical RL and irreversible pulpitis. |
| Planned crown and CDT code | D2740 planned for #4, PA radiograph enclosed |
| Prognosis with treatment planned crown | Plan D2740 or D2751 with good prognosis post-RCT |
As a reminder, criteria for laboratory-processed crowns are noted in the Medi-Cal Dental handbook (see link below). There must be:
- Gross pathologic destruction of the crown of the tooth, usually due to caries.
- No cosmetic or replacing tooth structure due to attrition, abrasion, or erosion.
- No cosmetic reconstruction or opening of the vertical dimension of occlusion as rationale for crowns.
- Good oral hygiene demonstrated, tooth vitality, and a prognosis of good or better for the tooth being treatment planned for the crown.
Additional criteria for:
Anterior teeth:
Destruction of the crowns of the front teeth must have four (4) or more surfaces plus a line angle. The line angle for the facial and lingual are not considered unless they wrap around the tooth to at least the midline, or if more than 50% of the front tooth crown is destroyed.
Pre-molars
Crowns are ok if Root Canal Treatment (RCT) treated within six (6) months. If not RCT treated, then the coronal destruction must involve three (3) or more surfaces plus a cusp. If RCT was done more than six (6) months ago – clearly state prognosis of tooth and any other circumstances around tooth that might impact tooth longevity.
Molars
Crowns are ok if RCT treated within six (6) months. If not RCT treated, then they must show destruction of four (4) or more surfaces plus two (2) or more cusps.
Resources:
Questions? Contact the HPSM Dental team.