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The American Dental Association’s Current Dental Terminology (CDT) notes that a core buildup, including any pins when required (D2950), “Refers to building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation.”
The purpose of a buildup is to obtain sufficient vertical height and width to support an extracoronal restoration, i.e., a crown. For both clinical justification and insurance coverage, “sufficient” refers to cases where there is extensive loss of tooth structure due to caries or tooth fracture, and there is not enough tooth strength and/or retention to support a crown and prevent its dislodgement.
A buildup is generally indicated when the following criteria are met:
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Structural Loss: 50% or more of tooth structure is carious or fractured, and/or evidence of cuspal fracture;
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Subgingival Preparation: The preparation is at or below the gingival crest; and
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Lack of Opposing Wall Continuity: Less than 3 mm of sound dentin remains vertically above the preparation line in opposing walls where the crown's margin will be located.
Consistent with the ADA definition, a buildup will not be approved when the procedure only involves a filler to eliminate any undercut, box for or irregularity in the preparation, or if it does not meet the criteria noted above. As an example, an occlusal or lingual restoration to fill an endodontic access prep, does not qualify as a buildup. Additionally, if a submission does not meet the definition of a buildup and is denied, the patient cannot be billed.
Denials for buildups can be a source of frustration; it is important to be aware of the criteria before submitting a claim. If you do get a denial and wish to appeal the decision, be sure to provide additional detail in the form of radiographs, photos and/or a narrative.
Michael D. Weitzner, DMD, MS
Dental Director, Delta Dental of Virginia
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