D2750 - Crown (PFM HN)
Crown - porcelain fused to high noble metal.
- Procedure Code
- D2750
- Category
- Restorative
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental 2026
- Frequency Limitation
- 1 per tooth in a 60-month interval (5 years) (rolling_12_months)
- Age Limitation
- Restricted to patients age 12 or older. Crowns and onlays are denied for children under 12 years of age.
- Downgrade Policy Warning
- Subject to LEPAT (Least Expensive Professionally Accepted Treatment); may be payable as full cast metal (D2790) on molars under restrictive contracts.
Required Claim Attachments & Pre-Submission Checklist
- Diagnostic pre-operative radiograph showing affected tooth/area
- Pre-operative treatment narrative and clinical rationale
Bill When (Allowable Clinical Criteria)
- Indicated when remaining tooth structure cannot be adequately restored with direct amalgam or composite restorations.
Restrictions & Clinical Exclusions
- Crowns and indirectly fabricated restorations are considered to be an optional benefit unless the tooth is damaged by decay or fracture to the point that it cannot be restored with amalgam or resin. Benefits are denied.
- Restorative benefits are made for the least expensive professionally accepted treatment procedure (LEPAT). Any difference in the fee is denied.
- If the deciduous tooth is an “extra tooth” in addition to the normal complement of teeth, a crown is not a benefit. Benefits are denied and the approved amount is chargeable to the patient.
- If a crown is being proposed or has been done where periodontal bone support appears to be inadequate, benefits are denied due to the unfavorable prognosis for the tooth.
- Tooth preparation, temporary restorations, laboratory fees and material, cement bases, impressions, occlusal adjustment, gingivectomies (on the same date of service) and local anesthesia are considered to be included in the fee for a crown restoration. Separate fees for these procedures by the same dentist/dental office are not billable to the patient on the same date of service.
- Crowns and onlays are not a benefit for children under 12 years of age. Benefits for patient under age 12 are denied.
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Benefit maximum or frequency limitation exceeded for procedure | Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria. |
| CO-96 | Non-covered charge / Downgraded under Least Expensive Professionally Accepted Treatment (LEPAT) | Submit clinical photographs and narrative documenting why the alternate benefit material is clinically contraindicated. |
ICD-10 Justification & Crosswalk Mappings
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|---|---|---|---|---|
| K02.63 | Dental caries on smooth surface penetrating into pulp | Dental caries | Yes (Primary) | BOTH | crown – porcelain fused to high noble metal indicated for Dental caries on smooth surface penetrating into pulp |
| K00.2 | Abnormalities of size and form of teeth | Disorders of tooth development and eruption | Secondary | BOTH | crown – porcelain fused to high noble metal indicated for Abnormalities of size and form of teeth |
| K02.52 | Dental caries on pit and fissure surface penetrating into dentin | Dental caries | Secondary | BOTH | crown – porcelain fused to high noble metal indicated for Dental caries on pit and fissure surface penetrating into dentin |
| K02.53 | Dental caries on pit and fissure surface penetrating into pulp | Dental caries | Secondary | BOTH | crown – porcelain fused to high noble metal indicated for Dental caries on pit and fissure surface penetrating into pulp |
| K02.62 | Dental caries on smooth surface penetrating into dentin | Dental caries | Secondary | BOTH | crown – porcelain fused to high noble metal indicated for Dental caries on smooth surface penetrating into dentin |
| S02.5XXA | Fracture of tooth (traumatic), initial encounter for closed fracture | Fracture of skull and facial bones | Secondary | BOTH | crown – porcelain fused to high noble metal indicated for Fracture of tooth (traumatic), initial encounter for closed fracture |