Crown — Full Cast High Noble Metal Template

Crown - full cast high noble metal.

RMH: Medical history reviewed/updates
Vitals: BP/pulse; other vitals if indicated

Tooth: #Tooth number(s)
Indication: Indication/diagnosis

Crown code support: Extent of decay/fracture and surfaces involved
Prior restoration/crown: Material/size/condition; placement date/age if replacement
Reason for crown/replacement: Full-coverage need/recurrent decay/open margin/fracture/etc.
Endodontic status/prognosis: Vital/RCT treated; symptoms/no symptoms; prognosis
Periodontal status/prognosis: Bone loss/SRP history/mobility or none; prognosis
Image labels: Diagnostic-quality radiographs/photos labeled tooth/date

Radiographs/photos: Radiographs/photos reviewed/taken and findings

Consent: Consent/PARQ reviewed; signed/verbally obtained

Anesthesia: Anesthetic used
Carps: Carpules/amount

Preparation Appointment:
Existing restoration removed.
Caries excavated.
Tooth prepared for full cast crown.
Adequate reduction verified.
Margins: Margins
Impression/scan taken.
Opposing impression taken.
Bite registration taken.
Provisional fabricated and cemented with temp cement.
Occlusion checked.
Contacts checked.

Lab:
Material: High noble metal.

Cementation Appointment:
Provisional removed.
Crown tried in.
Fit verified.
Marginal integrity verified.
Contacts verified.
Occlusion verified.
Crown cemented with: Cement used
Excess cement removed.
Final occlusion check.
Final polish.

Complications: None or describe.

Patient tolerance: Tolerance/response.

Post-op instructions: Instructions reviewed.

NV: Next visit

Documentation requirements

Crown documentation has to support why a full-coverage indirect restoration is necessary on this tooth and why high noble metal is the right material choice — direct restoration vs. crown is the first audit hook, material class is the second. A defensible D2790 note includes:

• Tooth number — universal numbering. D2790 is a permanent-dentition code; primary teeth get stainless-steel crowns (D2930/D2934).
• Indication / diagnosis — specific clinical finding driving full coverage: large failed restoration, fractured cusp(s), cracked tooth syndrome, post-endodontic protection, severe attrition with loss of vertical dimension on the tooth, recurrent caries undermining cusps. Generic "needs a crown" is weak; "fractured DL cusp #18 with crack extending subgingivally on the distal" is strong.
• Crown code support (full-coverage rationale) — the line that defends the indirect restoration over a large composite or onlay. Note remaining tooth structure (walls present, cusp integrity, ferrule), undermined cusps, fracture lines, and prior restoration footprint. Explicitly state why a direct restoration or onlay would be inadequate (e.g., "remaining buccal and lingual walls undermined; less than 50% coronal tooth structure remains; cuspal coverage required").
• Prior restoration / crown (replacement cases) — material of the prior crown or large restoration, approximate placement date or age, and the specific defect (open margin, recurrent decay subgingival on distal, fracture of porcelain veneer, decementation x2, etc.). Carriers commonly enforce 5-year (60-month) crown-replacement frequency on D2790; replacement inside that window requires a narrative and image support.
• Reason for crown / replacement — restate the clinical reason succinctly. "Recurrent caries under existing PFM with open distal margin" is auditable; "patient wants a new crown" is not.
• Endodontic status / prognosis — vital vs RCT-treated, symptoms vs asymptomatic, periapical findings, and prognosis. A tooth with questionable pulpal status crowned without an evaluation is a recurring audit and recoupment target. If RCT-treated, note the RCT date and any post/core (D2950/D2954) — the buildup is its own line item with its own documentation requirements.
• Periodontal status / prognosis — pocket depths around the tooth, mobility, bone loss, SRP history, attachment level. A tooth with a guarded periodontal prognosis crowned without a documented perio rationale is a frequent denial trigger; some carriers explicitly require periodontal-stability language for D2790.
• Image labels — diagnostic-quality periapical (preferred) and bitewing labeled with tooth number and date, plus pre-op intraoral photo of the existing tooth/restoration. Pre- and post-prep photos materially strengthen audit defense, especially for replacement cases where the prior crown's defect must be documented before it is removed.
• Material details (alloy class) — explicitly state high noble alloy and, ideally, the specific alloy product (e.g., Argedent 75, Firmilay, Olympia). The lab invoice and alloy certificate should be retained in the chart or scanned to the patient record. Several state Medicaid programs require the alloy certificate to be submitted with the claim or held on file.
• Margin design and location — chamfer / shoulder / shoulder with bevel; supragingival / equigingival / subgingival; circumferential ferrule height. High noble alloys allow thinner, more conservative margin geometries (chamfer at 0.5-0.8 mm) than ceramic; record what you actually prepped.
• Reduction adequacy — occlusal, axial, and functional cusp reduction verified (typically 1.0-1.5 mm occlusal for high noble cast metal, less than PFM or ceramic). Note reduction guides used (silicone index, putty matrix) if any.
• Impression / digital scan — material (PVS, polyether) or scanner (iTero, TRIOS, Primescan); opposing impression and bite registration / interocclusal records. If retraction was used, note method (cord size, hemostatic agent) — gingival management is part of the defensible record for marginal integrity.
• Provisional — material (Protemp, Integrity, Luxatemp), shade if applicable, cementation with temporary cement (TempBond, TempBond NE, TempoCem), occlusion and contacts checked.
• Lab instructions — alloy class, occlusal scheme, contacts, margin design, opposing dentition notes, and any specific patient considerations (bruxism, opposing crown material). The lab Rx is the documentary backbone of D2790 and is the artifact most carriers request first on audit.
• Cementation appointment — provisional removal, try-in (fit, marginal integrity, proximal contacts with floss, occlusion in centric and excursive movements), cement used (definitive cement: zinc phosphate, glass ionomer like Ketac Cem, RMGI like RelyX Luting Plus, or resin-modified depending on retention/case). Excess cement removal is critical and should be explicitly documented; subgingival residual cement is a leading cause of late peri-implantitis-style soft-tissue inflammation around natural-tooth crowns too.
• Anesthesia — agent, concentration, vasoconstrictor, and number of carpules at both prep and (if needed) cementation.
• Consent / PARQ — material alternatives (PFM, monolithic zirconia, all-ceramic), risks (post-op sensitivity, need for endo, future fracture, decementation, allergy in rare cases), costs and PPO downgrade if applicable. Document any patient gold-allergy screen — true gold/nickel hypersensitivity is rare but documented in the literature; a contact-dermatitis history or known metal-jewelry reaction is the standard chart trigger.
• Complications — explicit "none" or describe (pulp exposure during prep, gingival laceration during cord placement, contact opens at cementation requiring adjustment).
• Patient tolerance / response — tolerated well, mild sensitivity managed, no adverse events.
• Post-op instructions — provisional care (avoid sticky/hard foods, floss carefully and pull through interproximally rather than up, call if it dislodges), post-cementation sensitivity expectations, occlusion check follow-up.
• Next visit — cementation appointment date if separate from prep, occlusion check at recall, recall interval.

Two recurring "soft" defects to avoid: (1) a defaulted-template note that lists every step on the body even when half weren't actually performed (e.g., "opposing impression taken" on a digital workflow), and (2) silence on alloy class — a note that says only "crown prepped" without identifying high noble vs noble vs base metal cannot defend the D2790 fee against a downgrade audit.

Common denial reasons

The most frequent reasons D2790 is denied, downgraded, or recouped:

• Alternate-benefit downgrade to D2792 or D2791 — the dominant economic outcome. Carrier pays at noble or base-metal fee schedule; office must collect the difference or write it off depending on PPO contract. Not a "denial" technically, but the most common payment surprise.
• Replacement inside frequency window (typically 5 years) — second crown on the same tooth without narrative + radiograph showing fracture, recurrent caries, or trauma. Auto-denial.
• No alloy certificate / unable to substantiate high noble class — carrier requests the lab alloy certificate on audit; the office can't produce one or the certificate shows the alloy was actually noble (D2792) or predominantly base metal (D2791). Recoupment to the lower fee schedule.
• Tooth not restorable — radiographs show extensive bone loss, severe mobility, insufficient ferrule, or vertical root fracture. The crown isn't expected to last and is denied as not medically necessary. Periodontal status/prognosis documentation is the standard override.
• No clear indication for full coverage — the chart doesn't justify crown vs. large composite or onlay. Remaining tooth structure looks adequate on the bitewing, no fracture lines, no cuspal involvement, no recent endo. Carrier requests records and downgrades or denies.
• Anterior D2790 submission — D2790 on #6-#11 or #22-#27. Most carriers deny outright because esthetic alternatives are clinically appropriate; a few will alternate-benefit to D2740 (all-ceramic).
• Pre-authorization not obtained — PPO required pre-auth for crowns above an allowed threshold; office submitted without one. Standard "no pre-auth" denial; some carriers will accept retro-auth with narrative, others won't.
• Buildup miscoded as inclusive in crown — D2950 billed same date but documentation doesn't show >50% missing tooth structure or doesn't establish the buildup as required for crown retention. Carrier denies the D2950 as inclusive; the D2790 still pays.
• Same-tooth conflict — D2790 billed alongside another full-coverage code on the same tooth/date (D2740, D2750, D2780-D2783). Only one final restoration per tooth pays; the carrier picks one and denies the other.
• Endodontic prognosis silent — tooth was symptomatic at prep, no pulp test results documented, no plan for endodontic referral. Crown prepped on a tooth that needs RCT first is a quality-of-care denial pattern in Medicaid audits.
• Default-template wording — every D2790 note in the chart reads identically (same margins, same shade, same complications, same instructions). Pattern-recognized as fabricated by auditors and a recurrent finding in state OIG audits of dental practices.
• Interim crown billed as definitive — D2799 (interim crown) submitted as D2790; carrier discovers a final crown was placed later and recoups the duplicative payment. Bill D2799 if the crown is interim and re-bill D2790 only when the definitive crown is placed.

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