CurrentAnthemPolicy 06-001

Dental Clinical Policy - Implant/Abutment Supported Fixed Prosthetics Crowns and Fixed Partial Dentures

Defines clinical indications, documentation and coverage considerations for dental implant/abutment supported crowns and fixed partial dentures for Anthem members, including exclusions, contract-dependent provisions, and coding references (CDT codes listed for informational purposes).

Policy Summary

PayerAnthem

PolicyDental Clinical Policy - Implant/Abutment Supported Fixed Prosthetics Crowns and Fixed Partial Dentures

Policy CodePolicy 06-001

Change TypeMinor editorial refinements (10/29/2024)

Effective DateJan 1, 2025

Next Review Date

Key ActionPrior to implant placement and restoration, complete a thorough dental evaluation, medical/dental history, full mouth imaging, treatment plan, and include current (within 12 months) dated diagnostic preoperative radiographic images; if necessity is not obvious include intra-oral photographs and a narrative.

SourceLink

POLICY UPDATE CHANGES

Minor editorial refinements to description, clinical indications, and criteria; intent unchanged.

06-001Policy Number

CDT listReferenced Code Set

ConditionalCoverage

2024-10-29Last Review

Coverage Summary

Policy 06-001 (effective 2025-01-01) provides coverage guidance for Implant/Abutment Supported Crowns and Fixed Partial Dentures. Coverage stance: Conditional (mixed). Scope: defines clinical indications, documentation and coverage considerations for dental implant/abutment supported crowns and fixed partial dentures for Anthem members, including exclusions and contract-dependent provisions. Note: CDT codes are listed for informational purposes.

Policy metadata

Policy Number06-001

SubjectImplant/Abutment Supported Crowns and Fixed Partial Dentures

Effective Date01/01/2025

Last Review10/29/2024

Coverage Stancemixed

Referenced Code SetCDT list

Medical Necessity / Indications

Appropriate Indications (Medical Necessity)

Implant/abutment supported crowns and fixed partial dentures to replace missing teeth may be considered appropriate when:

ANY of the following

Accidental traumatic injuries to sound, natural teeth resulting in extraction/avulsion
Pathologic disorder: A pathologic disorder resulting in extraction
Congenital disorders of teeth resulting in extraction
Congenitally missing teeth

Referenced Codes (informational)

Referenced CDT Codes (informational)mixed

D6010	Surgical placement of implant body; endosteal implant.
D6011	Surgical access to an implant body (second stage implant surgery).
D6013	Surgical placement of mini implant.
D6055	Connecting bar implant or abutment supported.
D6056	Prefabricated abutment includes modification and placement.
D6057	Custom fabricated abutment - includes placement.
D6051	Interim implant abutment placement.
D6052	Semi-precision attachment abutment.
D6110	Implant/abutment supported removable denture for edentulous arch - maxillary.
D6111	Implant/abutment supported removable denture for edentulous arch - mandibular.

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Actions for Providers

Documentation Required

Complete preoperative documentation

Prior to implant placement and restoration, complete a thorough dental evaluation including medical and dental history, full mouth imaging, and a treatment plan. Include current (within 12 months), dated, diagnostic preoperative radiographic images. When radiographs do not clearly establish necessity, provide additional diagnostic information such as intra-oral photographs, patient treatment notes, and a narrative explaining extraordinary circumstances.

Thorough dental evaluation and medical/dental history
Full mouth imaging
Treatment plan
Current (within 12 months), dated diagnostic preoperative radiographs
Additional diagnostics if necessity not obvious (intra-oral photos, treatment notes, narrative)

Billing Rule

Background and Evidence

Dental implants are defined as surgical components used to replace missing teeth and the policy covers implant/abutment supported crowns and fixed partial dentures as the artificial tooth or teeth attached to implants/abutments. The policy notes that prosthetic restoration of dental implants may be subject to contract limitations and/or alternate benefit plan provisions, and that certain services (for example, replacements when teeth are not missing, third molar sites, or replacements for purely aesthetic reasons) are excluded or contract dependent.

Evidence supporting the policy references multiple guidelines and literature sources, including the ADA CDT 2025, specialty society position statements (for example, American Academy of Prosthodontists, American Association of Endodontists, American Academy of Periodontology), and systematic reviews and clinical studies on implant outcomes and related topics.

Definitions

Delivery dateDate considered for implant/abutment supported crowns and fixed partial dentures (contract dependent).

Revision History

2024-10-29clarified

Minor editorial refinements to description, clinical indications, and criteria; intent unchanged.

2025-01-01effective

Policy effective date.

ALL of the following

Teeth not missing: Teeth are not missing (including replacement of third molars); dental implant supported crowns and fixed partial dentures are not appropriate when teeth are not missing
Less costly alternatives: Replacement of multiple teeth by implant/abutment supported crowns or fixed partial dentures in the same arch is not medically necessary when other less costly professionally acceptable dental services can adequately restore occlusion to function (unless group contract specifies otherwise)
Third molar sites: Implant placement/restoration is not a covered benefit for third molar sites (contract dependent)
Aesthetic reasons: Replacement due to aesthetic reasons is not considered for benefits
Closure of contacts: Replacement to close contacts is not considered unless implant/abutment supported prosthetics are defective

Documentation and Timing Requirements

Coverage and claims require the following documentation and conditions:

ALL of the following

Pre-op evaluation: Prior to implant placement and restoration, a thorough dental evaluation, medical and dental history, full mouth imaging, and treatment plan must be completed
Radiograph recency: Documentation must include current (within 12 months), dated, diagnostic, preoperative radiographic imagesRadiograph recency: current (within 12 months)
Additional diagnostics: When necessity is not obvious by radiographic images, additional diagnostic information must accompany images (intra-oral photographs, patient treatment notes and narrative explaining extraordinary circumstances)
Incomplete service: If a subscriber does not return for delivery, there is no benefit as the service will be considered incomplete
Delivery date of implant/abutment supported crowns and fixed partial dentures is considered the date of delivery (dependent on provider contract)
Cement note: If cement is utilized, the type of cement (permanent or temporary) is not determinative for the delivery date (contract dependent)
Temporary inclusive: A temporary or provisional implant/abutment supported crown and fixed partial denture will be considered inclusive with the final restoration
Allergy documentation: Replacement due to metal allergy/sensitivity will be considered only upon submission of documentation by a physician with associated allergy report

Clinical Limitations / Evidence-based Considerations

Additional clinical limitations:

ALL of the following

Tooth-implant FPD survival: Tooth-implant supported fixed partial dentures may not be considered for benefits based on meta-analysis and studies showing lower survival rate compared to solely implant supported or solely tooth supported FPDs
Developmental/congenital defects: Implant placement may not be considered for correction of developmental or congenital defects (contract dependent)
Cantilever limitation: For cantilever implant/abutment supported fixed partial dentures, only one cantilever pontic may be an allowable benefit; peri-implant health of the retainers must be considered
Repair/replacement narrative: Repair and/or replacement of implant/abutment supported prosthetics (e.g., fractured porcelain) would require a detailed narrative (contract dependent)