The Non-Insured Health Benefits (NIHB) Program

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Crown Policy July 2011

Updated November 2012

1.0 General Principles

• The Non-Insured Health Benefits Program (NIHB) will consider coverage for a crown when both the eligibility and restorability criteria have been met.
• All crowns require a predetermination.
• There is a frequency limitation of one (1) crown in any three (3) year period per client.
• Only single unit metal or porcelain-fused to metal crowns are eligible under the NIHB Program.
• Porcelain/ceramic crowns, including fortified/reinforced porcelain/ceramic crowns, are not a covered benefit under the NIHB Program (exclusions).
• All basic treatmentaddressing any existing active biological disease (caries and periodontal), must be completed before submitting requests for crowns.
• The NIHB Program will not consider coverage for a crown:
  • to improve aesthetics;
  • to treat sensitivity due to cracked tooth syndrome, erosion, abrasion or attrition;
  • to treat stress fractures or chipping on teeth that have a minimal restoration or no restoration; and
  • for high caries risk individuals or those with generalized moderate to severe periodontal disease when there is evidence of long-standing, uncontrolled and/or untreated rampant biological disease (either caries or periodontal disease).

2.0 Predetermination Documentation Requirements for Crowns

The NIHB Program requires the following documentation for the review of a crown predetermination request:

• Predetermination request on one of the following forms: Complete Standard Dental Claim Form, ACDQ Dental Claim and Treatment Form, computer generated form, or NIHB Dental Claim Form (Dent-29).
• Comprehensive treatment plan from the treating and/or referring dentist/specialist, indicating all completed treatment and pending treatment needs including restorative, periodontal, prosthodontic, endodontic, orthodontic and surgical services.
• Current conventional or digital radiographs (within last twelve months).
  1. Periapical and bitewing radiographs:
     • must be of good diagnostic quality (i.e., size, resolution, contrast); and
     • must be mounted and labelled with the date of service, client name and provider name.
  2. A postoperative periapical radiograph must be submitted for a tooth that has been endodontically treated in the last 12 months.
  3. A panoramic radiograph may be submitted in addition to, but not in place of bitewing and periapical radiographs.

Please note: if duplicate radiographs are submitted they must identify the right or left side of the client's mouth.

When submitting enlarged digital radiographs, of any type, dental providers are requested to print a measurement scale on the radiograph to facilitate the assessment.

• Notation of all missing teeth.
• Periodontal charting, and/or Periodontal Screening and Recording (PSR), and/or Periodontal assessment.
• Periodontal measurements (6 sites/tooth) for the tooth/teeth under review.
• All pertinent clinical findings/notes supporting the predetermination request.

3.0 Tooth Eligibility

The NIHB Program will consider coverage of a single unit crown for:

• incisors, canines, bicuspids and first molars;
• second molars: may be considered for coverage where the first molar is missing and the second molar is in occlusion with a prosthetic or natural molar;
• clients 18 years of age and older; and
• eligible teeth, once per tooth in any eight (8) year period (96 months).

4.0 Tooth Restorability

The NIHB Program will consider coverage of a single unit crown on endodontically and non-endodontically treated teeth when all of the following criteria are met:

• Adequate periodontal support, based on alveolar bone levels (crown to root ratio of at least 1:1) visible on submitted radiographs with absence of furcation involvement;
• Absence of active periodontal disease;
• Adequate remaining non-diseased tooth structure to ensure that biologic width is maintained and adequate ferrule is achieved during restoration;
• An extensively restored tooth (more than four continuous surfaces), where the existing tooth structure can no longer support the direct restoration and where there is a repeated history of restoration failure;
• A mesio-distal width equivalent to that of the natural tooth with no loss of space due to caries or crowding;
• A tooth that does not require any additional treatment such as crown lengthening, root resectioning or orthodontic treatment; and
• Endodontically treated teeth must be proven successful as demonstrated on a postoperative periapical radiograph showing that healing has occurred.

5.0 Non-Inserted Crown Policy

The NIHB Program may consider paying up to 20% of the current NIHB professional fee and 100% of the laboratory fee, if applicable, for non-inserted crowns under the following conditions:

• The crown has been completed but not inserted due to circumstances beyond the control of the dental provider;
• The provider has made substantial efforts to contact the client to schedule an insertion appointment; and
• The provider has communicated the details of the situation in writing to their respective dental predetermination office.

Please note: A non-inserted crown that has been claimed and paid in full, without complying with the above noted conditions, will result in recovery.