D6608 Onlay Porcelain/Ceramic, Two Surfaces NO NO Not Covered – D6609 Onlay Porcelain/Ceramic, Three or More Surfaces NO NO Not Covered – D6610 Onlay Cast High Noble Metal, Two Surfaces NO NO Not Covered – D6611 Onlay - Cast High Noble Metal, Three or More Surfaces NO NO Not Covered D6612 Onlay - Cast Predominantly Base Metal, Two Surfaces NO NO Not Covered D6613 - Cast Predominantly Base Metal, Three or More NO NO Not Covered Surfaces Onlay - Cast Noble Metal, Two Surfaces NO NO Not Covered D6615 Onlay - Cast Noble Metal, Three or More Surfaces NO NO Not Covered D6624 Inlay - Titanium NO NO Not Covered D6634 Onlay - Titanium NO NO Not Covered FIXED PARTIAL DENTURE RETAINERS - CROWNS Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Code under age 21 age 21 & under age age 21 & & all over when 21 & all over allowed ICF-IID when residents* 25.04 residents allowed under 25.04 D6710 Crown - Indirect Resin Based Composite NO NO Not Covered D6720 Crown - Resin with High Noble Metal No No Not Covered D6721 Crown - Resin with Predominantly Base Metal No No Not Covered D6722 Crown - Resin with Noble Metal No No Not Covered D6740 Crown - Porcelain/Ceramic No NO Not Covered D6750 Crown - Porcelain Fused to High Noble Metal No No Not Covered D6751 - Porcelain Fused to Predominantly Base Metal No No Not Covered D6752 Crown - Porcelain Fused to Noble Metal No No Not Covered D6780 - 3/4 Cast High Noble Metal No No Not Covered
D6608 Onlay – Porcelain/Ceramic, Two Surfaces NO NO Not Covered D6609 Onlay – Porcelain/Ceramic, Three or More Surfaces NO NO Not Covered D6610 Onlay – Cast High Noble Metal, Two Surfaces NO NO Not Covered D6611 Onlay - Cast High Noble Metal, Three or More Surfaces NO NO Not Covered D6612 Onlay - Cast Predominantly Base Metal, Two Surfaces NO NO Not Covered D6613 - Cast Predominantly Base Metal, Three or More Surfaces NO NO Not Covered Onlay - Cast Noble Metal, Two Surfaces NO NO Not Covered D6615 Onlay - Cast Noble Metal, Three or More Surfaces NO NO Not Covered D6624 Inlay - Titanium NO NO Not Covered D6634 Onlay - Titanium NO NO Not Covered FIXED PARTIAL DENTURE RETAINERS - CROWNS Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max under age 21 & all residents* age 21 & over when allowed 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D6710 Crown - Indirect Resin Based Composite NO NO Not Covered D6720 Crown - Resin with High Noble Metal No No Not Covered D6721 Crown - Resin with Predominantly Base Metal No No Not Covered D6722 Crown - Resin with Noble Metal No No Not Covered D6740 Crown - Porcelain/Ceramic No NO Not Covered D6750 Crown - Porcelain Fused to High Noble Metal No No Not Covered D6751 - Porcelain Fused to Predominantly Base Metal No No Not Covered D6752 Crown - Porcelain Fused to Noble Metal No No Not Covered D6780 - 3/4 Cast High Noble Metal No No Not Covered