Non-Insured Health Benefits
Crown Policy - October 2005
Help on accessing alternative formats, such
as PDF, MP3 and WAV files, can be obtained in the alternate
format help section.
 (40 KB)
The objective of this policy is to clarify the decision making
process as currently applied when funding single crowns (metal
or porcelain-fused to metal) as well as any associated treatment.
All crowns will require predetermination.
The following criteria must be met with each submission
for consideration of funding for single unit crowns:
Complete Documentation Including:
- completed Standard Dental Claim Form, l'Association des chirurgiens
dentistes du Québec (ACDQ) Dental Claim and Treatment
Form, computer generated form, or NIHB DENT-29 Form;
- current radiographs including bitewings, panoramic radiographs,
and/or any periapical films specific to the requested treatment;
- radiographs should identify the client, provider and must be
mounted, dated and of acceptable quality to enable predetermination
of the proposed treatment; and
- a comprehensive treatment plan addressing all treatment needs
for the mouth. If active biological disease is present (caries
and periodontal disease), all treatment to address that disease
must be completed before submitting for single unit crowns.
Funding for a single unit crown will be approved when
both the functionality and restorability of the tooth (teeth)
requested have been met.
Determination of Functionality of Teeth
- The Non-Insured Health Benefits (NIHB) Program will consider
funding of a single unit crown for functional teeth that have
been previously endodontically treated and/or are extensively
restored, are deemed to be essential in maintaining a stable
occlusion, and/or are critical abutments for any planned removable
prosthodontic treatment; and
- A vital or non-vital tooth that has an existing extensive restoration
that can no longer function as an independent restoration. Endodontically
treated teeth will be considered for a single unit crown following
completion of endodontic therapy, and demonstrated success as
evidenced by a current post-treatment periapical film and (if
required) provider comments.
Determination of Restorable Teeth
Restorability will be established by reviewing all submitted documentation
for:
- a favourable crown-root ratio (at least 1:1);
- adequate periodontal support, based on alveolar bone levels
(at least greater than 50%) visible on submitted radiographs
with absence of furcation involvement, in addition to further
supporting documentation, where necessary, indicating mobility
and attachment loss;
- adequate remaining non-diseased tooth structure to ensure that
biologic width is maintained; and
- no need for complex treatment such as crown lengthening, root
re-sectioning or orthodontic treatment.
Single unit crowns will not be funded when:
- the functionality and restorability of the tooth/teeth cannot
be established;
- there is evidence of uncontrolled biological disease (either
caries or periodontal disease);
- the client is under the age of 18 years;
- the crown is being placed to improve aesthetics; and
- an existing crown is less than 8 years old, and replacement
is being requested. All requests for replacement must include
the age of the existing crown in addition to a rationale for
replacement.
Non-inserted crown policy
Crowns that are not inserted, but the provider has informed NIHB,
the program will pay 100% of the lab and 20% of the professional
fee when lab has been completed on a crown. The billing service
date to be used when submitting a claim is the date of the last
visit to the provider/office.
If the provider has wrongfully billed the program and it is found
in an audit or through the predetermination process, there will
be a zero tolerance and all monies will be recovered.
|
