# Dental frequency limitations > What are dental frequency limitations, and how do you confirm the one that applies to a claim? Verified in named plan documents; honest about everything that is plan-dependent. URL: https://dentovio.com/dental-frequency-limitations Last verified: 2026-08-31 Dentovio is an independent publisher — not an insurance carrier, benefits administrator, the American Dental Association, or any government agency, and it is unaffiliated with the payers named here. This page was drafted with AI assistance and verified against the primary sources linked here. It has not been reviewed by a credentialed dental billing specialist or attorney. Missing tooth clauses, downgrades, and frequency limits are contract terms: each rule here was read in the one named plan document, payer policy, or program manual cited beside it on the last-verified date, and none of them is a payer-wide standard — several of the payers say so in their own words. Plan documents govern, editions change, and a summary is not the contract. CDT codes appear by number only; plain-language names are Dentovio paraphrases and no ADA descriptor text is reproduced. Educational reference only, not legal, benefits, or billing advice; confirm the controlling term in the patient's certificate or policy before quoting a patient or submitting a claim. ## Direct answer A frequency limitation caps how often a plan pays for a service, and it is a contract term rather than a payer standard: Guardian publishes no frequency figure at all and states that plan documents are the final arbiter of coverage, and Aetna publishes no crown frequency baseline in any of its dental clinical policy bulletins. Verified in named documents: crown replacement windows run from 24 months to 10 years — 24 and 36 months for prefabricated and stainless steel crowns on one Guardian Utah plan, 36 months in South Carolina Medicaid, five years on Aetna's California DMO and in both United Concordia government programs, 60 months on one Delta Dental Insurance Company group PPO, 84 months in Colorado Medicaid, and 10 years on one MetLife-authored plan-summary form. Preventive rules differ in kind as well as number: one DentaQuest Ohio policy gives under-19 members a six-month interval and adults twice per calendar year, one Delta group plan pays examinations, cleanings, periodontal maintenance, and scaling in the presence of inflammation twice per calendar year in any combination, and MetLife's federal plan moved routine exams and cleanings from one in six months to two in twelve months for 2026 while capping replacement fillings at one in 24 months. The counting method matters as much as the allowance — calendar year, rolling 12 months, or six months from the last date of service — and prior-carrier service dates can count against the clock. Waiting periods, annual maximums, and program caps frequently bind before any frequency rule does. ## What is payer-level here, and what is not Almost nothing here is payer-level, and two payers say so outright: Guardian publishes no frequency baseline and Aetna publishes no crown frequency at all. The payer-level facts that do exist are program rules — MetLife's 2026 federal changes, United Concordia's five-year interval in FEDVIP and TRICARE, the state Medicaid contracts DentaQuest administers. Every commercial number below belongs to one named plan, and the question set is how you get to yours. ## What the documents say ### Examinations, cleanings, fluoride, and sealants #### DentaQuest (Ohio individual PPO) — One named plan DentaQuest PPO Family High Plan, Ohio individual and family market, effective January 1, 2026. Document date: Effective January 1, 2026. **Adults:** Twice per calendar year This policy runs two different clocks by age. Under 19: periodic exam, bitewings, and routine cleaning once every six months each. Age 19 and over: periodic exam twice every calendar year, one set of bitewings twice every calendar year, cleaning twice every calendar year — and the comprehensive oral examination once every sixty months. > Comprehensive oral examination (including the initial dental history and charting of teeth); once every sixty (60) months. Periodic exam; twice every calendar year. Caveats that travel with this: - Twice every calendar year is not once every six months. Two adult cleanings in the same calendar year are payable with no minimum interval, and the counter resets on January 1 rather than running from the last date of service. - The attached Schedule of Benefits adds a medical-necessity qualifier to the under-19 bitewing line — "once every six (6) months when oral conditions indicate need" — and the Schedule is the operative attachment. - Adult waiting periods bite before frequency does: six months on Basic and other restorative services, twelve months on Complex and Major. There is no waiting period under 19. Sources: - [DentaQuest PPO for Individuals and Families — Ohio Family High Plan policy](https://www.dentaquest.com/content/dam/dentaquest/en/members/ohio/oh-ppo-family-high-plan-policy.pdf) — Part II Benefits, PDF p. 7 (under 19) and PDF p. 9 (19 and over); Schedule of Benefits PDF pp. 32, 34; waiting periods PDF p. 37 (Governing plan document) #### Delta Dental Ins. Co. (one group PPO) — One named plan Evidence of Coverage for Mississippi State University, Group No. 01125, effective January 1, 2024. Document date: Effective January 1, 2024. **Shared bucket:** Twice per calendar year On this plan the twice-a-year allowance is one shared bucket, not one per service. Oral examinations, cleanings, scaling in the presence of generalized moderate or severe gingival inflammation, and periodontal maintenance are payable no more than twice in a calendar year in any combination. > We will pay for oral examinations… and cleanings (including scaling in the presence of generalized moderate or severe gingival inflammation-full mouth, periodontal maintenance in the presence of inflamed gums or any combination thereof) no more than twice in a Calendar Year. Caveats that travel with this: - Periodontal maintenance is paid as a Major benefit while routine cleanings are Diagnostic and Preventive — same bucket, different coinsurance tier. - Additional cleanings are available during pregnancy, a common exception to a flat twice-a-year statement. - One 2024 group PPO plan for one employer, not a Delta-wide rule. Sources: - [Delta Dental Insurance Company — Evidence of Coverage, Mississippi State University (Group 01125)](https://www.hrm.msstate.edu/sites/www.hrm.msstate.edu/files/2024-03/Delta%20Dental%20Evidence%20of%20Coverage.pdf) — Attachment B, Limitations (2)(a), form ENT-LE-MS-22, p. 1 (Governing plan document) #### Delta Dental Ins. Co. (one group PPO) — One named plan The same Mississippi State University group EOC. Document date: Effective January 1, 2024. **Sealants:** Through age 15 Topical fluoride is limited to enrollees to age 19 and no more than twice in a calendar year. Sealants are limited through age 15 on permanent molars without caries or restorations on the occlusal surface, and repair or replacement of a sealant within 24 months of its application is included in the fee for the original placement. > Sealants are limited as follows: a) through age 15 on permanent molars if they are without caries (decay) or restorations on the occlusal surface. b) repair or replacement of a Sealant on any tooth within 24 months of its application is included in the fee for the original placement. Caveats that travel with this: - There is no 60-month sealant replacement rule in this document. The limits are an age cap and a 24-month included-in-the-original rule. - The restriction is narrower than "unrestored": specifically without caries or restorations on the occlusal surface. Sources: - [Delta Dental Insurance Company — Evidence of Coverage, Mississippi State University (Group 01125)](https://www.hrm.msstate.edu/sites/www.hrm.msstate.edu/files/2024-03/Delta%20Dental%20Evidence%20of%20Coverage.pdf) — Attachment B, Limitations (4) and (9), form ENT-LE-MS-22, pp. 1–2 (Governing plan document) #### MetLife (AOP association plan) — One named plan A MetLife dental PPO offered through an association, as described on the broker's plan-benefits page. Document date: Stated effective January 1, 2025 through December 31, 2026. **Interval:** One every six months On this plan prophylaxis and oral examinations are limited to one every six months — a stricter interval rule than two in twelve months, on the same carrier, in the same year. The plan's waiting-period ladder is zero months for Type A preventive, six months for Type B basic, and twelve months for Type C major and Type D orthodontia. Caveats that travel with this: - This is a broker and association enrollment page, not an EOC. It disclaims itself: "This webpage is provided for summary purposes only and is not a complete description of the plan benefits, limitations, and exclusions. Read your certificate of insurance for details." The governing certificate is not published there. - Orthodontia — and therefore its twelve-month wait — exists only on the High PPO tier; the Low PPO tier shows orthodontia as not included. - The page states one effective period covering January 1, 2025 through December 31, 2026, so do not restate it as a single plan year. Sources: - [MetLife dental PPO plan benefits (association plan, broker summary page)](https://memberbenefits.com/individuals/dental-and-vision/aop-dental-plan-benefits/) — Coverage Type table and the plan-limitations rows; disclaimer block at foot of page (Summary (defers to a contract)) #### Cigna (one self-funded group booklet) — One named plan The 2018 self-funded group certificate booklet administered by Cigna. Document date: Effective July 1, 2018; provision form HC-DEN3 04-10 V5. **Cleanings:** 3 per contract year This booklet allows two clinical oral examinations, three cleanings, and two bitewing charges per person per contract year, and one complete series or panoramic film per person in any 36 consecutive months — with the full-mouth series and the panoramic film sharing a single limit. > X-rays – Complete series or Panoramic (Panorex) – Only one per person, including panoramic film, in any 36 consecutive months. Caveats that travel with this: - Cigna's own employer page states a different set of typical numbers — two cleanings per calendar year, one bitewing per calendar year, one full-mouth X-ray every five calendar years and one panorex every five calendar years — and hedges it with "Plans may vary." The two Cigna sources contradict each other, which is the point: there is no single Cigna baseline to publish. - This booklet also relaxes limits in the other direction: certain frequency limitations may be relaxed for pregnant women, diabetics, or those with cardiac disease. - One self-funded group's 2018 booklet. Do not present it as current Cigna practice. Sources: - [Cigna Dental Preferred Provider Insurance certificate booklet (self-funded group, ASO)](https://www.un.org/insurance/sites/www.un.org.insurance/files/mpd_cigna_dpo.pdf) — Printed p. 11, form HC-DEN3 04-10 V5; relaxation provision form HC-POB5 04-10 (Governing plan document) - [Cigna Healthcare — group dental insurance plans for employers](https://www.cigna.com/employers/dental-and-vision/dental) — Footnote 3 (typical preventive frequencies, "Plans may vary") (Summary (defers to a contract)) ### Radiographs #### DentaQuest (Ohio individual PPO) — One named plan The same Ohio Family High Plan policy, both age bands. Document date: Effective January 1, 2026. **Full-mouth images:** 60 months X-rays of the entire mouth are limited to once every sixty months in both age bands. That is the policy's own wording; it never uses the abbreviation FMX or a CDT code for it, and single-tooth images are payable as needed. Caveats that travel with this: - The word "panoramic" appears nowhere in the 39-page policy. No panoramic frequency can be attributed to this plan, and a 60-month panoramic limit is not in evidence here. Sources: - [DentaQuest PPO for Individuals and Families — Ohio Family High Plan policy](https://www.dentaquest.com/content/dam/dentaquest/en/members/ohio/oh-ppo-family-high-plan-policy.pdf) — PDF p. 7 (printed p. 6) and PDF p. 9 (printed p. 8) (Governing plan document) ### Crowns and restorations #### DentaQuest (Ohio individual PPO) — One named plan The same Ohio Family High Plan policy. Document date: Effective January 1, 2026. **Crowns:** 60 months per tooth Crowns and onlays are covered once per tooth per sixty months, and only where the tooth cannot be restored with a filling because of severe decay or fracture; replacement runs on the same sixty-month per-tooth clock. Complete or partial dentures and fixed bridges run once every sixty months, and replacement additionally requires that the existing prosthesis cannot be made serviceable and was inserted at least sixty months earlier. Fillings carry a separate 24-month per-surface replacement bar. > Replacement of dentures and fixed bridges, but only when they cannot be made serviceable and were inserted at least sixty (60) months before replacement Caveats that travel with this: - The serviceability test is a second, independent condition — meeting the sixty months alone does not make a replacement payable. - The policy states no per-arch denture limit. The word "arch" does not appear in it. Sources: - [DentaQuest PPO for Individuals and Families — Ohio Family High Plan policy](https://www.dentaquest.com/content/dam/dentaquest/en/members/ohio/oh-ppo-family-high-plan-policy.pdf) — PDF p. 9 (under 19, Complex & Major) and PDF p. 11 (19 and over); Schedule of Benefits PDF pp. 34, 36 (Governing plan document) #### Delta Dental Ins. Co. (one group PPO) — One named plan The same Mississippi State University group EOC. Document date: Effective January 1, 2024. **Crowns:** 60 months, age 12+ Crowns and inlays or onlays are limited to enrollees age 12 and older and covered not more often than once in any sixty-month period, unless the existing restoration is not satisfactory and cannot be made satisfactory because the tooth has experienced extensive loss or changes to tooth structure or supporting tissues. The same sixty-month clock also governs core buildups, posts and cores, fixed denture repairs, and prosthodontic replacement. > Crowns and Inlays/Onlays are limited to Enrollees age 12 and older and are covered not more often than once in any 60 month period except when We determine the existing Crown or Inlay/Onlay is not satisfactory and cannot be made satisfactory… Caveats that travel with this: - Sixty months here is a family of rules, not a crown-only rule — and it is one 2024 group plan's number, not an industry standard. Sources: - [Delta Dental Insurance Company — Evidence of Coverage, Mississippi State University (Group 01125)](https://www.hrm.msstate.edu/sites/www.hrm.msstate.edu/files/2024-03/Delta%20Dental%20Evidence%20of%20Coverage.pdf) — Attachment B, Limitations (24)–(29), form ENT-LE-MS-22, p. 4 (Governing plan document) #### Guardian (Utah EHB plan) — One named plan Utah Essential Health Benefit — Guardian Preventive Plus, child and adult benefit sets. Document date: 2021 filing (form IP-DENF-SCH6-21-UT). **Crowns:** 24 and 36 months The only crown frequencies stated in this document are short ones: prefabricated crowns once per tooth in a 24-month period on the child plan, and stainless steel crowns once per 36-month period on the adult plan for teeth not restorable by a filling. Its five-year replacement rule names a full denture, partial denture, or fixed bridge — crowns are absent from it — and the clock runs from the last replacement, not from initial placement. > Replacement of a full denture, partial denture, or fixed bridge is covered when: 5 years have elapsed since last replacement of the denture or bridge; OR the denture or bridge was damaged while in the Covered Person's mouth when an injury was suffered… Caveats that travel with this: - The document never uses "60 months" or "fixed partial denture" — it says five years and fixed bridge. Do not paraphrase a contract into vocabulary it does not use. - A related clause bars replacing an extracted tooth where it was an abutment of an existing prosthesis less than five years old. - A 2021 filing whose currency is not established. Sources: - [Guardian — Utah Essential Health Benefit, Preventive Plus (form IP-DENF-SCH6-21-UT)](https://assets.ctfassets.net/jrhizl9l7csx/2fB548PZO75ULiuxTfaeQm/2b7ff3a8b74afd9f8cdf28f4a727d22d/UT_IP-DENF-SCH6-EXCH_21.pdf) — p. 3 child prefabricated crowns; p. 5 adult stainless steel crowns; p. 7 Denture or Bridge Replacement/Addition (Summary (defers to a contract)) ### Prosthetic replacement #### Cigna (one self-funded group booklet) — One named plan The same 2018 self-funded group booklet. Document date: Effective July 1, 2018; provision form HC-DEX1 04-10 V1. **Prosthetics:** 5 years + serviceability Two separate provisions govern replacement here, and they are often compressed into one. A bridge, crown, or denture cannot be replaced within five years of installation unless the replacement is made necessary by placing an original opposing full denture, by the necessary extraction of natural teeth, or by damage beyond repair from an injury suffered while insured. Separately and with no time limit at all, no replacement is covered for a prosthesis that is or can be made useable by common dental standards. > any replacement of a bridge, crown or denture which is or can be made useable according to common dental standards Caveats that travel with this: - Serviceability is a standing bar, not a five-year carve-out: a useable prosthesis is not replaceable at any age on this plan. - Cigna's Dental Care (DHMO) product publishes different standard limitations — crowns, inlays, and prosthesis over implant one per five years, and replacement of a surgical implant one every ten years. That is a stated DHMO limitation, not an employer-negotiated option. Sources: - [Cigna Dental Preferred Provider Insurance certificate booklet (self-funded group, ASO)](https://www.un.org/insurance/sites/www.un.org.insurance/files/mpd_cigna_dpo.pdf) — Printed p. 13, form HC-DEX1 04-10 V1 (Governing plan document) - [Cigna Healthcare — group dental insurance plans for employers](https://www.cigna.com/employers/dental-and-vision/dental) — Footnote 7 (Cigna Dental Care DHMO limitations) (Summary (defers to a contract)) #### Aetna DMO (California) — One named plan Aetna's California DMO products, as documented in one county group EOC and one 2025 disclosure matrix. Document date: EOC plan revision effective January 1, 2024; disclosure matrix effective January 1 – December 31, 2025. **Replacement:** 5 years Aetna's California DMO documents carry a five-year replacement limit on crowns, inlays, onlays, veneers, complete dentures, removable partial dentures, and bridges, and allow scaling and root planing at four separate quadrants per 24 months. The 2025 disclosure matrix for this DMO records no deductible, no annual maximum, no waiting period — and no out-of-network coverage at all. Caveats that travel with this: - DMO, not PPO. Both documents describe closed-network products where out-of-network is flatly not covered, so no PPO figure can be drawn from them. - These are group employer plans — a county and a large employer — not individual-market products. - The EOC defers all other frequency limits to a schedule of benefits issued separately and not bound into the posted file, so no cleaning, bitewing, or full-mouth-series frequency can be sourced here. Sources: - [Aetna Dental of California DMO Evidence of Coverage (County of San Luis Obispo)](https://www.slocounty.ca.gov/departments/human-resources/forms-documents/benefits/dental-vision/aetna-dmo-evidence-of-coverage-(eoc)-2025) — Replacement limits, printed p. 13 (Governing plan document) - [Summary of Dental Benefits and Coverage Disclosure Matrix, Aetna Dental DMO (2025)](https://jpmcbenefits.aetna.com/application/files/2717/2738/2513/JPMC_2025_SDBC.pdf) — Part I General Information and the limitations column, printed pp. 1, 3–4 (Summary (defers to a contract)) #### United Concordia FEDVIP and TRICARE Dental Program — Program-wide rule United Concordia's FEDVIP brochure (plan year 2025) and the TRICARE Dental Program Handbook Supplement (January 2026). Document date: FEDVIP plan year 2025; TDP Handbook Supplement January 2026. **Crowns:** 1 in 5 years Both United Concordia programs run a five-year interval on major restorative work. In FEDVIP a laboratory crown is limited to one per five years per tooth, and the crowns that anchor a fixed bridge carry the same five-year limit. In the TRICARE Dental Program crowns, onlays, buildups, and posts and cores are one in five years, with replacement covered only where the existing restoration cannot be made serviceable. TDP measures the five years from the actual day and month of the initial service, not from the first of that month. > The five-year service date is measured based on the actual date (i.e., day and month) of the initial service, rather than the first day of the month during which the initial service was received. Caveats that travel with this: - TDP carries an exception no secondary summary mentions: the five-year limitation does not apply where the member moves at least 40 miles from the original servicing location on a Permanent Change of Station relocation, with orders required. - United Concordia's FEDVIP brochure is pinned to plan year 2025 — the OPM endpoint 404s for 2026 — so re-confirm current participation before presenting it as live coverage. - These are government programs. Nothing here supports a statement about United Concordia commercial plans, whose manuals are all login-gated. - TDP frequencies are set by contract with the Defense Health Agency, not fixed by regulation: 32 CFR 199.13(e)(2)(x) delegates limitations to the Director and states no frequency of its own. Sources: - [TRICARE Dental Program Handbook Supplement (January 2026)](https://www.uccitdp.com/content/dam/ucd/en/sites/uccitdp/branded/tdp/docs/TDPHandbookSupplement.pdf) — § 8.1.7 replacement rule; § 11.1.18 measurement rule and PCS waiver; § 12.1.4 implants (Governing plan document) - [United Concordia Dental FEDVIP brochure (2025)](https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plans/BrochureJson?brochureNumber=United%20Con&year=2025) — Section 5, Class C major restorative and prosthodontic detail tables (Governing plan document) - [32 CFR § 199.13 — TRICARE Dental Program](https://www.ecfr.gov/current/title-32/section-199.13) — (e)(2)(x), benefit limitations and exclusions (Federal regulation) ### A published change worth knowing #### MetLife FEDVIP — Program-wide rule The MetLife Federal Dental Plan, 2026 plan year, under OPM contract OPM02-FEDVIP-02AP-11 — the brochure is the official statement of benefits. Document date: 2026 plan year (January 1 – December 31, 2026). **2026:** 2 in 12 months For 2026 this plan moved routine examinations and prophylaxis cleanings from a one-in-six-months interval to two in twelve months, and put a first-ever limit on replacement fillings of one in 24 months. The same change list moved general anesthesia from Class B to Class C coinsurance and occlusal guards from one in 12 months to one in 24. > Changing the frequency limitation of routine examinations and prophylaxis cleanings from 1 in 6 months to 2 in 12 months Caveats that travel with this: - This is the clearest published example of an interval rule becoming a count rule. The two are not equivalent, and the change was made deliberately. - FEDVIP uses Class A/B/C/D (Basic, Intermediate, Major, Orthodontic), which is a different taxonomy from the Type A/B/C/D used on many commercial plan summaries. Cross-labelling the two misstates both. - Prior-carrier history counts here: the brochure states that even where a crown or partial bridge was not placed while covered under this plan, the frequency limitations may apply. Sources: - [The MetLife Federal Dental Plan 2026 brochure (OPM, contract OPM02-FEDVIP-02AP-11)](https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plans/BrochureJson?brochureNumber=02AP-11&year=2026) — "How We Have Changed for 2026 — Standard & High Option Changes"; Class A limitation notes (Governing plan document) ### Payers that publish no baseline at all #### Guardian — No published standard Guardian's public dental plan pages. Document date: Read 2026-08-31. **Published baseline:** None Guardian publishes no cleaning, examination, or radiograph frequency figure anywhere on its public site. It states only that most plans pay all or most of the charge for checkups and cleanings, and that plan documents are the final arbiter of coverage, with availability, benefits, and deductibles varying by state. > Plan documents are the final arbiter of coverage Caveats that travel with this: - A sentence beginning "Guardian's baseline is…" cannot be sourced. Any Guardian frequency figure in circulation belongs to a named group plan, not to the carrier. Sources: - [Guardian — dental insurance plans](https://www.guardianlife.com/dental-insurance/plans) — Coverage description and plan-document disclaimer (Payer-published policy) #### Guardian Dental Guard Preferred, Group #381084 — One named plan One union welfare fund's transcribed summary of its Guardian Dental Guard Preferred plan, Group Plan #381084. Document date: Undated page; footer © 2024 PSC-CUNY Welfare Fund; carries a March 2026 change. **Cleanings:** 3 per calendar year This named group plan allows three prophylaxes or periodontal maintenance treatments per calendar year and one full-mouth series or panoramic film in any 60 consecutive months. Three per year is a purchased enhancement, not a Guardian default: the fund markets its own rate sheet as "Enhanced Fee Codes" and states elsewhere on the same page that standard prophylactic care is covered once every four months. Caveats that travel with this: - The page is transcribed by the welfare fund, not issued by the carrier, and it is internally inconsistent — the same CDT code for periodontal root planing appears at both 24 and 36 months. - The same page carries a second carrier's limits side by side, so any figure lifted from it must be checked against which carrier it belongs to. - Sixty months for a full-mouth series is an outlier even among the sources read for these pages: a verification vendor describing a Guardian plan reports 36 months, and the other carrier on this very page runs 24. Sources: - [PSC-CUNY Welfare Fund — dental benefits (Guardian Dental Guard Preferred, Group #381084)](https://www.psccunywf.org/actives/welfare-fund-benefits/dental/) — "Guardian Dental Program Procedural Limitations by Frequency, Age, and Annual Maximum" (Summary (defers to a contract)) #### Vendor-reported counting methods — One named plan A verification vendor's field guide to Guardian plans — a commercial third party, not a payer document. Document date: Published August 28, 2026. **Counting methods:** Three in circulation The same allowance can be counted three different ways: by calendar year, by rolling 12 months, or by six months from the last date of service. A verification vendor reports all three on Guardian plans and advises offices to confirm which one applies, because an estimate can be wrong even when the benefit exists. > Guardian plans may apply frequencies by calendar year, rolling 12 months, or every six months from the last date of service. Those are not the same. Caveats that travel with this: - Attributed to Teero, a dental staffing and verification vendor whose commercial content markets the service it recommends. Nothing in it says Guardian imposes a verification requirement on offices — that is vendor best practice, not a payer mandate. - Read it as a checklist prompt rather than as a coverage fact. The counting method for a specific plan comes from that plan's documents. Sources: - [Teero — Guardian dental verification field guide (vendor blog)](https://www.teero.com/blog/guardian-dental-verification-the-coverage-details-offices-miss) — "Frequency limits are more restrictive than staff expect" (Third-party vendor source) #### Aetna — No published standard Aetna's public claim guidance and its complete Dental Clinical Policy Bulletin catalogue. Document date: Undated pages; read 2026-08-31. **Crown frequency:** Not published Aetna publishes no crown frequency baseline. Its Dental Clinical Policy Bulletins do not govern crown frequency or crown replacement at all, and the bulletins expressly do not describe plan benefits. Aetna's own nearest statement points the other way: each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. > While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. Caveats that travel with this: - Aetna's Dental Office Guides, where plan-level frequency detail would live, sit behind the provider login. - A widely repeated "Aetna 60-month crown frequency" has no Aetna document behind it. It is not published here, in the bulletins, or in any Aetna page that could be read. Sources: - [Aetna Dental Clinical Policy Bulletins — terms of use and bulletin index](https://www.aetna.com/health-care-professionals/clinical-policy-bulletins/dental-clinical-policy-bulletins.html) — Acceptance block, ¶¶ 1–2; full bulletin index (Payer-published policy) - [Aetna Dental — Downcoding & Bundling (claim submission tips and guidelines)](https://www.aetnadental.com/professionals/claim-submission-guidelines/downcoding-bundling.html) — Full-page term scan for frequency language (Payer-published policy) #### Delta Dental of Michigan — Payer-stated policy Delta Dental of Michigan's published clinical criteria for utilization review. Document date: Undated; annual review stated. Read 2026-08-31.. **Prophylaxis:** Set by oral condition This member company separates two questions that are routinely conflated. Benefit coverage is determined by the specific terms of a member's dental plan — but the frequency of prophylaxis appointments should be determined by the patient's oral condition, including caries risk, periodontal risk, and the need to control local irritational factors. > The frequency of dental prophylaxis appointments should be determined based on the patient's oral condition, including the risk of caries, risk of periodontal disease and the need to control local irritational factors Caveats that travel with this: - Delta Dental of Michigan is a separate member company from Delta Dental Insurance Company, with separately adopted criteria. Do not merge the two into one Delta policy. - The page is structured as two parallel and materially different criteria sets, adults and children. Quoting across that boundary produces a wrong rule. - No version number and no effective date is published — the page states only that criteria are reviewed at least annually. Read 2026-08-31. Sources: - [Delta Dental of Michigan — clinical criteria](https://www.deltadentalmi.com/dentists/tools-resources/clinical-criteria) — "Understanding medical necessity and coverage determinations"; adult prophylaxis criteria (Payer-published policy) ### Medicaid and CHIP programs #### DentaQuest Medicaid (Colorado and South Carolina) — Program-wide rule Health First Colorado's dental Office Reference Manual and the South Carolina Department of Health and Human Services dental provider manual. Document date: Colorado manual footer July 1, 2026; South Carolina manual January 1, 2026. **Crowns:** 84 months CO / 36 months SC Two states, one administrator, different numbers. Colorado limits crowns on permanent teeth to one every seven years (84 months) and complete, immediate, and partial dentures to once every seven years with prior authorization required. South Carolina limits prefabricated crowns to one per 36 months per tooth and covers no laboratory crowns for adults, while its dentures run 60 months. Colorado's dentures are exempt from the $3,000 adult annual cap. Caveats that travel with this: - There is no payer-wide DentaQuest standard. Each row is set by the state contract, which is why a single "DentaQuest crown frequency" figure is indefensible. - Frequency exceptions in Colorado run through EPSDT and stop at 21. For adults, over-limit care is member liability with written acknowledgment. - The Colorado manual self-stamps proprietary and confidential despite public linking, so it is paraphrased here rather than reproduced. Sources: - [Health First Colorado (Medicaid) dental Office Reference Manual — DentaQuest, LLC](https://www.dentaquest.com/content/dam/dentaquest/en/providers/colorado/co-health-first-office-reference-manual.pdf.coredownload.inline.pdf) — § 8.02 crown criteria, p. 62; § 5.00 Prosthodontics, pp. 41–42 (Government program manual) - [South Carolina Department of Health and Human Services — Dental Services Provider Manual (January 1, 2026)](https://provider.scdhhs.gov/internet/pdf/manuals/dental/Manual.pdf) — Appendix procedure rows: prefabricated crowns 36 months; complete dentures 60 months (Government program manual) ## Crown replacement, as the documents state it The "60-month industry standard" is not what the plan documents say. Every row below was read in the named document. | Document | Replacement window | Note | | --- | --- | --- | | Guardian, Utah EHB Preventive Plus (child) | 24 months | Prefabricated crowns, once per tooth. | | Guardian, Utah EHB Preventive Plus (adult) | 36 months | Stainless steel crowns, for teeth not restorable by a filling. | | South Carolina Medicaid (DentaQuest as administrator) | 36 months | Prefabricated crowns per tooth; no laboratory crowns for adults. | | Aetna Dental of California DMO | 5 years | Crowns, inlays, onlays, veneers, dentures, partials, and bridges. | | United Concordia FEDVIP (2025) and the TRICARE Dental Program | 5 years | Per tooth, with a serviceability condition in TDP and a relocation waiver. | | Cigna, one self-funded group booklet (2018) | 5 years | Plus a standing bar on replacing any prosthesis that can be made useable. | | MetLife plan-summary form, a second group (form DN-ANY-PPO-DUAL) | 5 calendar years | Crowns, inlays, and onlays — the same carrier, a different group. | | Delta Dental Insurance Company, one 2024 group PPO | 60 months | Age 12 and older, with a not-satisfactory exception; buildups and prosthetics share the clock. | | Health First Colorado (DentaQuest as administrator) | 84 months | Crowns on permanent teeth, one every seven years. | | MetLife plan-summary form (form DN-ANY-PPO-STAND, hosted on metlife.com) | 10 years | Crowns, inlays, and onlays — twice the interval of the form above. | ## Questions that settle a specific plan ### Which age band does this patient fall into, and does the document carry separate pediatric and adult benefit lists? **Why it matters:** One Ohio policy read for these pages runs six-month intervals under 19 and twice-per-calendar-year counts at 19 and over. Quoting one band's rule to the other misdescribes the benefit in a way a patient could act on. **Where the answer lives:** The benefits part of the policy — look for two separate lists — and the attached schedule of benefits, which is usually the operative attachment. ### Is the limit an interval (once every six months) or a count per benefit period (twice per calendar year)? **Why it matters:** They are not the same benefit. Under a count, two visits can fall in consecutive weeks and the counter resets on January 1. MetLife's federal plan deliberately moved from one to the other for 2026. **Where the answer lives:** The exact wording of the limitation line. Ask the payer to read it, not to summarize it. ### What is the benefit period — calendar year, contract or plan year, or rolling 12 months — and when does it reset? **Why it matters:** A verification vendor reports three counting methods in circulation on one carrier's plans, including six months from the last date of service. The allowance means nothing until you know how it is counted. **Where the answer lives:** The definitions section for the benefit-year definition, plus the payer's eligibility portal for the reset date. ### Do examinations, cleanings, periodontal maintenance, and scaling in the presence of inflammation share one allowance? **Why it matters:** One Delta group plan pays these no more than twice in a calendar year in any combination, so a periodontal maintenance visit consumes a cleaning. It also pays maintenance at the major tier while cleanings sit at preventive. **Where the answer lives:** The limitations attachment. Look for "or any combination thereof" in the preventive limitation. ### Is the clock measured from the actual day and month of the prior service, or from the first of that month? **Why it matters:** The TRICARE Dental Program states the day-and-month rule expressly. A plan measuring from the first of the month gives back up to 30 days, and that is often the whole dispute. **Where the answer lives:** The replacement-limitation paragraph in the handbook or certificate. ### Do service dates under the prior carrier count against this plan's frequency and replacement limits? **Why it matters:** Federal dental brochures read for these pages say they may — even where the crown or bridge was never placed under or paid by this plan. A patient who switched carriers is not starting a fresh clock. **Where the answer lives:** The frequency-limitation preamble, and the payer's own history for that tooth. ### For crowns and prosthetics, is the clock per tooth, per arch, or combined across all major prosthodontics — and does it run from initial placement or from the last replacement? **Why it matters:** One federal plan combines every major prosthodontic service under a single five-year limitation covering the whole arch. One Guardian plan runs its five years from the last replacement, not from initial placement. The scope changes who is eligible and when. **Where the answer lives:** The prosthodontic replacement limitation, and the general exclusions where the combination rule often hides. ### Is there a serviceability condition in addition to the interval? **Why it matters:** Several documents require both: the interval has elapsed and the existing restoration cannot be made serviceable. On one Cigna booklet the serviceability bar has no time limit at all, so a useable prosthesis is never replaceable. **Where the answer lives:** The replacement clause — usually the sentence beginning "unless" or "but only when". ### What exceptions does the plan actually publish? **Why it matters:** Limits also move in the patient's favour: one booklet relaxes certain frequency limits for pregnant women, diabetics, and cardiac patients; one Delta group plan adds cleanings during pregnancy; Colorado Medicaid allows frequency exceptions through EPSDT for members 20 and younger; the TRICARE Dental Program waives its five-year rule on a qualifying relocation. **Where the answer lives:** The limitations section, the program's medical-necessity or EPSDT provisions, and any published exception request process. ### Before quoting frequency, check what binds first — a waiting period, an annual maximum, or a program cap. **Why it matters:** An Ohio policy applies six- and twelve-month waiting periods to adult restorative work, which makes a 60-month crown limit moot in year one. Texas CHIP's $564 annual limit binds before most frequency rules. One Guardian plan pays 0% for the major class outright. **Where the answer lives:** The schedule grid: waiting periods, deductible, annual maximum, and the coinsurance for the relevant class. ### Which version of the document are you reading? **Why it matters:** Program manuals amend on a fixed cycle — the Colorado manual states it updates quarterly — and a superseded edition stays findable online long after it stops being true. One payer's clinical criteria read for these pages carry a cover effective date of January 1, 2025 on a file generated in December 2025, so even the edition line can be ambiguous. **Where the answer lives:** The cover version number, the footer date stamp, and the revision history at the back. ## Standing constraints ### The contract overrides the manual, the summary, and the payer policy Every document behind these pages subordinates itself to an instrument we usually have not read. A Cigna outline of coverage states plainly that it is not the insurance contract and only the policy provisions control. An Aetna DMO evidence of coverage says the group agreement must be consulted for the exact terms. Aetna's clinical policy bulletins say they do not constitute a description of plan benefits. MetLife's plan summaries defer to the certificate of insurance. Read the number here as the default in a named document, then confirm it in the contract that governs the claim. - [Cigna Dental Vision 1000 Plan — Outline of Coverage (Pennsylvania)](https://www.cigna.com/static/www-cigna-com/docs/ifp/d-ooc-pa-941453-pennsylvania-cigna-dental-vision-1000.pdf) — p. 1, "This is not the insurance contract and only the actual Policy provisions will control." - [Aetna Dental of California DMO Evidence of Coverage (County of San Luis Obispo)](https://www.slocounty.ca.gov/departments/human-resources/forms-documents/benefits/dental-vision/aetna-dmo-evidence-of-coverage-(eoc)-2025) — "The health plan group agreement must be consulted to determine the exact terms and conditions of coverage." - [MetLife dental PPO plan benefits (association plan, broker summary page)](https://memberbenefits.com/individuals/dental-and-vision/aop-dental-plan-benefits/) — Disclaimer block: "Read your certificate of insurance for details on plan benefits, limitations, and exclusions." ### There is no payer-wide standard, and four payers say so themselves Guardian states that plan documents are the final arbiter of coverage and publishes no frequency figure at all. Cigna hedges its own numbers with "Plans may vary" and says benefits vary by plan type. Aetna says most of its plans contain alternate benefit language but that provisions may vary among employers and other plan sponsors. Delta Dental of Michigan says that where a program sets its own criteria or other limitations, those apply — refer to the specific plan or office manual. Write "on the plan documented at this citation, the limit is N", never "this payer's standard is N". - [Guardian — dental insurance plans](https://www.guardianlife.com/dental-insurance/plans) — "Plan documents are the final arbiter of coverage" - [Aetna Dental — Downcoding & Bundling](https://www.aetnadental.com/professionals/claim-submission-guidelines/downcoding-bundling.html) — ABP preamble: provisions "may vary among employers (and other plan sponsors, such as unions)" - [Delta Dental of Michigan — clinical criteria](https://www.deltadentalmi.com/dentists/tools-resources/clinical-criteria) — "Please refer to the specific dental plan, provider or office manual for details." ### Member advice and provider rules are not the same instruction United Concordia's alternate-benefit brief is written to members and federal benefits officers: it encourages the member to ask for a predetermination when a treatment plan is estimated at $300 or more. MetLife recommends that the member request a pre-treatment estimate above $300 — its term is pre-treatment estimate, not predetermination, and no benefit is forfeited by skipping it. Cigna's predetermination is expressly voluntary, is not preauthorization, and is not a guarantee of a set payment. None of the three is a claims-processing requirement, and none of them can be restated as a submission rule. - [United Concordia Dental FEDVIP — Understanding Alternate Benefit Provision](https://www.uccifedvip.com/agency-benefits-officers/benefit-briefs/alternate-benefit-provision) — Body copy, paragraph 4 - [MetLife dental plan summary, form DN-ANY-PPO-STAND](https://www.metlife.com/content/dam/metlifecom/us/homepage/Martin-Resource-Management/PDF/Martin-Resource-Management-FF451-Dental-Summary.doc) — Pre-treatment estimate paragraph - [Cigna Dental Vision 1000 Plan — Outline of Coverage (Pennsylvania)](https://www.cigna.com/static/www-cigna-com/docs/ifp/d-ooc-pa-941453-pennsylvania-cigna-dental-vision-1000.pdf) — p. 6, Sec. G, predetermination ### Prior coverage counts against the clock — and that is not a missing tooth clause Rather than excluding a pre-existing space, several large plans carry the frequency clock forward. One FEDVIP carrier states that where services subject to a frequency limitation were performed before the effective date of coverage, the date of that prior service may count toward the time, frequency, and replacement limitations — even if the crown or bridge was never placed under, or paid by, this plan. That produces a different denial and a different appeal from a missing tooth clause: the question becomes when the previous restoration was placed, not when the tooth was lost. - [BCBS FEP Dental brochure 02AP-03 (2026)](https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plans/pdf/2026/brochures/02AP-03.pdf) — Printed p. 33 (also pp. 27, 31) - [The MetLife Federal Dental Plan 2026 brochure](https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plans/BrochureJson?brochureNumber=02AP-11&year=2026) — Frequency limitations and prior coverage ### Four different instruments, four different appeals A missing tooth clause turns on whether the tooth was already missing when the policy started. A replacement rule turns on when the extraction happened relative to the existing prosthesis. A frequency-clock carryover turns on when the previous restoration was placed, including under a prior carrier. An arch-level prosthodontic cap combines every major prosthodontic service under one replacement limitation, so paying for a partial denture consumes the benefit for every tooth in that arch. Each was read in a real document for these pages, and each produces a different denial. Naming the wrong one loses the appeal before it starts. - [Aetna Dental of California DMO Evidence of Coverage (replacement rule)](https://www.slocounty.ca.gov/departments/human-resources/forms-documents/benefits/dental-vision/aetna-dmo-evidence-of-coverage-(eoc)-2025) — Replacement rule, printed pp. 12–13 - [United Concordia Dental FEDVIP brochure (arch-level replacement limitation)](https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plans/BrochureJson?brochureNumber=United%20Con&year=2025) — Section 7, General Exclusions - [Guardian — Utah Essential Health Benefit, Preventive Plus (missing teeth limitation)](https://assets.ctfassets.net/jrhizl9l7csx/2fB548PZO75ULiuxTfaeQm/2b7ff3a8b74afd9f8cdf28f4a727d22d/UT_IP-DENF-SCH6-EXCH_21.pdf) — p. 7, Missing Teeth Limitation ## Sources - [DentaQuest PPO for Individuals and Families — Ohio Family High Plan policy](https://www.dentaquest.com/content/dam/dentaquest/en/members/ohio/oh-ppo-family-high-plan-policy.pdf) — Part II Benefits, PDF p. 7 (under 19) and PDF p. 9 (19 and over); Schedule of Benefits PDF pp. 32, 34; waiting periods PDF p. 37 (Governing plan document) - [Delta Dental Insurance Company — Evidence of Coverage, Mississippi State University (Group 01125)](https://www.hrm.msstate.edu/sites/www.hrm.msstate.edu/files/2024-03/Delta%20Dental%20Evidence%20of%20Coverage.pdf) — Attachment B, Limitations (2)(a), form ENT-LE-MS-22, p. 1 (Governing plan document) - [The MetLife Federal Dental Plan 2026 brochure (OPM, contract OPM02-FEDVIP-02AP-11)](https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plans/BrochureJson?brochureNumber=02AP-11&year=2026) — "How We Have Changed for 2026 — Standard & High Option Changes"; Class A limitation notes (Governing plan document) - [MetLife dental PPO plan benefits (association plan, broker summary page)](https://memberbenefits.com/individuals/dental-and-vision/aop-dental-plan-benefits/) — Coverage Type table and the plan-limitations rows; disclaimer block at foot of page (Summary (defers to a contract)) - [Cigna Dental Preferred Provider Insurance certificate booklet (self-funded group, ASO)](https://www.un.org/insurance/sites/www.un.org.insurance/files/mpd_cigna_dpo.pdf) — Printed p. 11, form HC-DEN3 04-10 V5; relaxation provision form HC-POB5 04-10 (Governing plan document) - [Cigna Healthcare — group dental insurance plans for employers](https://www.cigna.com/employers/dental-and-vision/dental) — Footnote 3 (typical preventive frequencies, "Plans may vary") (Summary (defers to a contract)) - [Guardian — dental insurance plans](https://www.guardianlife.com/dental-insurance/plans) — Coverage description and plan-document disclaimer (Payer-published policy) - [PSC-CUNY Welfare Fund — dental benefits (Guardian Dental Guard Preferred, Group #381084)](https://www.psccunywf.org/actives/welfare-fund-benefits/dental/) — "Guardian Dental Program Procedural Limitations by Frequency, Age, and Annual Maximum" (Summary (defers to a contract)) - [Teero — Guardian dental verification field guide (vendor blog)](https://www.teero.com/blog/guardian-dental-verification-the-coverage-details-offices-miss) — "Frequency limits are more restrictive than staff expect" (Third-party vendor source) - [Guardian — Utah Essential Health Benefit, Preventive Plus (form IP-DENF-SCH6-21-UT)](https://assets.ctfassets.net/jrhizl9l7csx/2fB548PZO75ULiuxTfaeQm/2b7ff3a8b74afd9f8cdf28f4a727d22d/UT_IP-DENF-SCH6-EXCH_21.pdf) — p. 3 child prefabricated crowns; p. 5 adult stainless steel crowns; p. 7 Denture or Bridge Replacement/Addition (Summary (defers to a contract)) - [Aetna Dental of California DMO Evidence of Coverage (County of San Luis Obispo)](https://www.slocounty.ca.gov/departments/human-resources/forms-documents/benefits/dental-vision/aetna-dmo-evidence-of-coverage-(eoc)-2025) — Replacement limits, printed p. 13 (Governing plan document) - [Summary of Dental Benefits and Coverage Disclosure Matrix, Aetna Dental DMO (2025)](https://jpmcbenefits.aetna.com/application/files/2717/2738/2513/JPMC_2025_SDBC.pdf) — Part I General Information and the limitations column, printed pp. 1, 3–4 (Summary (defers to a contract)) - [Aetna Dental Clinical Policy Bulletins — terms of use and bulletin index](https://www.aetna.com/health-care-professionals/clinical-policy-bulletins/dental-clinical-policy-bulletins.html) — Acceptance block, ¶¶ 1–2; full bulletin index (Payer-published policy) - [Aetna Dental — Downcoding & Bundling (claim submission tips and guidelines)](https://www.aetnadental.com/professionals/claim-submission-guidelines/downcoding-bundling.html) — Full-page term scan for frequency language (Payer-published policy) - [TRICARE Dental Program Handbook Supplement (January 2026)](https://www.uccitdp.com/content/dam/ucd/en/sites/uccitdp/branded/tdp/docs/TDPHandbookSupplement.pdf) — § 8.1.7 replacement rule; § 11.1.18 measurement rule and PCS waiver; § 12.1.4 implants (Governing plan document) - [United Concordia Dental FEDVIP brochure (2025)](https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plans/BrochureJson?brochureNumber=United%20Con&year=2025) — Section 5, Class C major restorative and prosthodontic detail tables (Governing plan document) - [32 CFR § 199.13 — TRICARE Dental Program](https://www.ecfr.gov/current/title-32/section-199.13) — (e)(2)(x), benefit limitations and exclusions (Federal regulation) - [Health First Colorado (Medicaid) dental Office Reference Manual — DentaQuest, LLC](https://www.dentaquest.com/content/dam/dentaquest/en/providers/colorado/co-health-first-office-reference-manual.pdf.coredownload.inline.pdf) — § 8.02 crown criteria, p. 62; § 5.00 Prosthodontics, pp. 41–42 (Government program manual) - [South Carolina Department of Health and Human Services — Dental Services Provider Manual (January 1, 2026)](https://provider.scdhhs.gov/internet/pdf/manuals/dental/Manual.pdf) — Appendix procedure rows: prefabricated crowns 36 months; complete dentures 60 months (Government program manual) - [Delta Dental of Michigan — clinical criteria](https://www.deltadentalmi.com/dentists/tools-resources/clinical-criteria) — "Understanding medical necessity and coverage determinations"; adult prophylaxis criteria (Payer-published policy) - [Cigna Dental Vision 1000 Plan — Outline of Coverage (Pennsylvania)](https://www.cigna.com/static/www-cigna-com/docs/ifp/d-ooc-pa-941453-pennsylvania-cigna-dental-vision-1000.pdf) — p. 1, "This is not the insurance contract and only the actual Policy provisions will control." (Summary (defers to a contract)) - [United Concordia Dental FEDVIP — Understanding Alternate Benefit Provision](https://www.uccifedvip.com/agency-benefits-officers/benefit-briefs/alternate-benefit-provision) — Body copy, paragraph 4 (Payer-published policy) - [MetLife dental plan summary, form DN-ANY-PPO-STAND](https://www.metlife.com/content/dam/metlifecom/us/homepage/Martin-Resource-Management/PDF/Martin-Resource-Management-FF451-Dental-Summary.doc) — Pre-treatment estimate paragraph (Summary (defers to a contract)) - [BCBS FEP Dental brochure 02AP-03 (2026)](https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plans/pdf/2026/brochures/02AP-03.pdf) — Printed p. 33 (also pp. 27, 31) (Governing plan document) - [MetLife dental plan summary, form DN-ANY-PPO-DUAL (MetLife-authored form, broker-hosted copy)](https://ffbenefits.ffga.com/wp-content/uploads/sites/995/2025/10/Dental-Summary-MetLife-164789_FF451-StandAlone_2025-RATES.pdf) — Type C major restorative table, p. 2 (Summary (defers to a contract)) ## Related - [Dental insurance missing tooth clause](https://dentovio.com/dental-missing-tooth-clause/index.html.md) - [Dental insurance downgrades and alternate benefits](https://dentovio.com/dental-insurance-downgrades/index.html.md) - [Dental claim denial codes](https://dentovio.com/dental-claim-denial-codes/index.html.md) - [Payer documentation requirements](https://dentovio.com/dental-claim-documentation/index.html.md) - [Dental insurance verification](https://dentovio.com/dental-insurance-verification/index.html.md) - [Dental billing & claims hub](https://dentovio.com/dental-billing/index.html.md)