Get Major Restorative PREDs Approved with CDCP: for Dental Professionals

This article is for any dental professionals who may have stumbled across my page.

As we all know by now, getting major restorative like dental crowns and partial dentures approved through CDCP is no easy feat. Not to mention, PRED approvals for additional scaling units.

So what do we need to know in order to have an honest conversation with patients and set up the right expectations for coverage?

One of the biggest hurdles to successful treatment acceptance with CDCP is, right now, managing patient expectations. Now that there is this idea that CDCP is a comprehensive dental plan, and "crowns are covered" when it turns out their crown has been denied, it can be difficult to explain that doesn't mean the crown isn't needed.

Let's go over some of the requirements that must be met in order for a crown to be approved.

CDCP Requirements for Dental Crowns

1. Abscence of periodontal disease or encolsed treatment plan showing ongoing treatment of periodontal disease.

   1. Complete periodontal probing chart must be submitted with all mailed PRED ideally dated within the last 12 months. If older than 12 months, the periodontal charting must show full buccal and lingual numbers (6 per tooth) OR a written explanation why a periodontal chart could not be completed

      
      

2. Must be HEAVILY RESTORED

   1. Anterior teeth (endo tx and non-endo tx)

      1. Existing restoration or loss of structure involves FULL incisal edge from mesial to distal and extends cervically to both interpoximal contacts

         
         

3. For ENDO treated molars & premolars

   1. Resto or loss of structure involves 3 continuous surfaces aka full cusp

      1. The 3 continuos surfaces needs to stretch from mesial to distal (ie. MLD or MBD) and/or radiographs or diagnostic photos show destruction of full cusp

         
         

4. For NON ENDO molars & premolars [MOST COMMON]

   1. Existing restoration is 5 CONTINUOUS SURFACES. Entire tooth must have restorative material demonstrated with radiograph

      
      

5. If the tooth does not require further tx. ie. no crown lengthening, no ortho, periodontal health is managed

   
   

DENTIST ONLY CONSIDERATIONS (beyond the scope of your admin team)

1. Adequate alveolar bone levels (crown to root ratio of 1:1 or less e.g. 1:1.5 or 1:2), visible on submitted radiographs with absence of furcation involvement

2. Planned restoration margin is 3 mm from the alveolar crest and adequate ferrule (1.5mm)

3. Mesio-distal space (vertically and horizontally) equivalent to that of the natural tooth

CORES & POSTS

Only considered if crown PRED has been submitted and approved.

TOOTH NEEDS RCT BEFORE CROWN

For teeth that require a root canal prior to crown placement, the crown will only be considered once the root canal has been completed and healed. Very likely, after a restoration has been placed to close the access hole, the tooth is unlikely to be considered for a crown unless all other conditions are still met such as 3 continuously restored surfaces. An O resto post RCT is not enough.

FREQUENCY LIMITATIONS FOR CROWNS

• 4 crowns per 10 years per patient

• 1 crown in 8 years per eligible tooth

NOT COVERED

1. Implant crowns

2. Aesthetic crowns

3. Stress fractures or chips (with minimal or no existing restoration. Tooth must still meet all other requirements based on tooth type)

4. High risk of current/future caries or existing and untreated periodontal disease

5. Sensitivity

   1. due to: cracked tooth symdrom, attrition, erosion, or abrasion

5 cont: It's not super clear based on the current guidelines if diagnosed crack tooth syndrom teeth would still need to meet all other requirements such as existing 5 surface resto. I can offer nothing further in regards to coverage for this.

WISDOM TEETH CROWNS

• Eligible if 1st or 2nd molar is missing and/or the wisdom tooth is in occlusion with another molar

  • While unspecified, the wisdom tooth may also need to meet all other molar crown requirements, not simply in cases where the 2nd molar is missing

RECOMMENDATIONS

Due to some of the strict requirements for major coverage with CDCP, my recommendation for offices is to impress the importance of doing a Complete Oral Exam for CDCP patients which should include updating or completing a comprehensive periodontal chart and odontogram.

I would recommend that adequate radiographs are also taken for patients along with diagnostic photos for any patient that needs a PRED for major work.

In this regard, the need for periodontal charting for major claims is somewhat of an advantage for the office; any patients who had been declining x-rays, exams, or probing will need to be informed that all of these things are actually REQUIRED by Sunlife. Otherwise, when a dental emergency hits, they risk not being covered.

It is important we understand the coverage requirements when discussing recommended treatment with patients. You, or your front desk staff, should explain that the requirements for crowns are incredibly strict.

They do not consider risk of future fracture, such as endodontically treated molars as one example, as sufficient reason to pay for a crown. Essentially, the CDCP philosophy is: they would rather wait for catastrophic fracture and then pay for an extraction instead of pay now for a crown which could save that patients natural tooth for the next 10 years or more.

We really need to be able to approch this discussion in a way which helps patients understand that CDCP rejection of treatment does NOT mean it is not needed treatment. And that, although they can say they over crowns, the conditions are so strict that effectively they don't cover crowns in 80% of cases.

PARTIAL DENTURES

You'd think edentulous tissue would be reason enough to justify the need for a partial denture! Seems pretty simple, right? The patient is missing teeth and requires an appliance to replace those missing teeth in order to restore function.

Is that enough to get coverage with CDCP? Nope!

REQUIRED MISSING TEETH

1. A missing anterior tooth OR

2. 2 missing 6's

   1. Missing 7's or 8's does not count

So, for a posterior partial denture for example, the patient needs to be missing a (16, 26, 36, 46) and a (15, 25, 35, 45) in the same quadrant. Missing the very back molar and missing a wisdom tooth is irrelevant, even if the patient has occlusal contact with those molars on the opposing quadrant.

Or, if we are hoping to replace a missing 7 and the patient is not missing any 6's, the patient also needs to have a missing anterior tooth. How or why this would be relevant for a posterior partial is a mystery.

If there is an existing bridge replacing that anterior tooth, even though the tooth is still technically missing, it WILL NOT COUNT to the CDCP. In such cases, if that bridge also needs future replacement, it would be ideal to remove it prior to submitting a PRED for the PD.

Also required is, of course:

• a periodontal chart or indication that periodontal health is being managed either by yoursel or a referred specialist

• x-rays of abutment teeth ideally within the last 12 months

• diagnostic photos of both upper and lower arch (a scan likely qualifies as a photograph)

• an odontogram or notation of all missing teeth

• teeth numbers of all planned extractions if not already completed.

In conclusion...

As long as we begin the treatment conversation by setting reasonable expectations, and being honest with ourselves, our staff, and our patients, there shouldn't be any unfortunate surprises when a claim comes back with a rejection.

I can tell you from my own office, when all criteria are met, the major work is approved. I think we've all heard rumours from colleagues about so and so who is getting every crown approved but I can't say I've seen any evidence of that. In reality, many offices have been struggling to understand the requirements and getting rejection after rejection with no explanation.

Word of advice: If you can see that molar doesn't have a 5 surface resto, save the trees and save the paper. It's not getting covered!

Till next time,

Your Dental Receptionist