CurrentAnthemPolicy 06-101

Implant Body (Fixture) Guideline

Clinical guidance for evaluation and indications for placement of dental implant bodies (fixtures), documentation and imaging requirements, exclusions (e.g., multiple-tooth replacement when less costly alternatives exist) and circumstances that may qualify a patient for implant placement. It is intended for use in utilization review and does not by itself determine benefit coverage.

Policy Summary

PayerAnthem

PolicyImplant Body (Fixture) Guideline

Policy CodePolicy 06-101

Change TypeRevised

Effective Date

Next Review Date

Key ActionProviders must complete an evaluation of the functional occlusion and submit dated, properly oriented diagnostic full mouth, panoramic, and/or other appropriate radiographic images documenting bone levels and quality; panoramic or full mouth images must show all existing and missing teeth in both arches.

SourceLink

POLICY UPDATE CHANGES

Document status indicated as Revised with last review date 12/05/2020 and publish date 01/01/2021.

9Enumerated criteria items

10Referenced CDT codes (count)

1Policy guideline ID

Policy overview

Clinical criteria for considering implant placement

Clinical Criteria for Considering Implant Placement

Implant placement may be considered when ALL of the following applicable criteria are met:

ALL of the following

Evaluation of the functional occlusion of the entire dentition (mouth-oral cavity) must be completed prior to implant placement.
Dated, properly oriented, diagnostic full mouth, panoramic, and/or other appropriate radiographic images must be provided that document the bone levels and quality.
A panoramic image or full mouth images must reveal all existing and missing teeth in both upper and lower arches.
A comprehensive treatment plan may be requested including periodontal status.
May include documentation of a history of definitive periodontal treatment, including maintenance, for the remaining teeth.
Eligible clinical situations (ANY of the following)
- Replacement of teeth lost due to accidental traumatic injuries to sound, natural teeth from an external blow.
- Replacement of teeth lost as a result of removal of pathologic disorders or unrestorable teeth.
- Replacement of congenitally missing teeth.
Single-tooth replacement considerations
- In the absence of multiple missing teeth and active infection, single tooth replacement by a dental implant may be considered regardless of the need for full crown coverage of the teeth adjacent to the implant site.
- Benefits for implant placement for a second molar tooth are plan specific.
  Coverage may vary by group contract.
Patient-specific qualifiers (ANY of the following may qualify)
- A patient's documented sensitivity (allergy) to denture restorative materials may be considered a qualification for dental implant placement.
  Must be documented by a physician and dental provider's letters of medical/dental necessity and a copy of the laboratory analysis of the allergy.
- A patient's inability to wear a removable appliance due to limited retention may be considered a qualification for implant placement.
  Must be documented by a letter of dental necessity from the treating provider, supported by appropriate radiographic evidence, and a history of failed corrective procedures.
Immediate placement of a dental implant body (fixture) in a tooth extraction site is an acceptable procedure.
Implant placement may not be considered for the correction of developmental or congenital defects (congenitally missing teeth) unless covered by group contract.

Required documentation & utilization review actions

Documentation Required

Pre-placement evaluation and imaging

Providers must complete an evaluation of the functional occlusion of the entire dentition and submit dated, properly oriented diagnostic radiographic images that document bone levels and quality. A panoramic image or full mouth images must reveal all existing and missing teeth in both upper and lower arches.

Dated, properly oriented diagnostic full mouth images
Panoramic radiograph
Other appropriate radiographic images documenting bone levels and quality
Panoramic/full mouth images must show all existing and missing teeth in both arches

Documentation Required

Comprehensive treatment plan and periodontal documentation

A comprehensive treatment plan may be requested that includes the patient’s periodontal status. Documentation may include a history of definitive periodontal treatment and evidence of periodontal maintenance for the remaining teeth.

Comprehensive treatment plan including periodontal status
Documentation of history of definitive periodontal treatment and maintenance (may be requested)

Documentation Required

Allergy qualification documentation

When implant placement is claimed due to sensitivity (allergy) to denture restorative materials, the condition must be documented by both a physician's and the dental provider's letters of medical/dental necessity and accompanied by a copy of the laboratory analysis of the allergy.

Physician letter of medical necessity
Dental provider letter of medical/dental necessity
Copy of laboratory analysis documenting the allergy

Documentation Required

Inability to wear removable appliance documentation

If implant placement is claimed because the patient cannot wear a removable appliance due to limited retention, providers must submit a letter of dental necessity from the treating provider, supporting radiographic evidence, and documentation of a history of failed corrective procedures.

Letter of dental necessity from the treating provider
Appropriate supporting radiographic evidence
History/documentation of failed corrective procedures

Denial Risk

Alternate, less costly treatment

Replacement of multiple teeth by dental implants in the same arch may be denied when other less costly dental services can adequately restore occlusion to function. Prosthetic restoration of implants may be subject to alternate benefit provisions; benefit coverage depends on the member’s group contract.

Denial risk when less costly adequate alternatives exist
Prosthetic restoration may be subject to alternate benefit provisions
Coverage depends on group/plan contract

Relevant procedure codes (informational)

Relevant CDT procedure codes (informational)mixed

D6010	surgical placement of implant body (fixture): endosteal implant second stage implant surgery
D6011	surgical placement of implant body (fixture): endosteal implant second stage implant surgery
D6012	surgical placement of interim implant body (fixture) for transitional prosthesis: endosteal implant
D6013	surgical placement of mini implant
D6040	surgical placement: eposteal implant
D6050	surgical placement: transosteal implant
D6100	implant removal, by report
D7993	Surgical placement of craniofacial implant - extra oral
D7994	Surgical placement: zygomatic implant

Supporting evidence and references

Evidence summary: Multiple peer-reviewed clinical studies and American Academy of Periodontology position papers and commissioned reviews (references 1–22) support positive long-term implant outcomes, immediate implant placement into extraction sites, bone augmentation techniques using barrier membranes, and the importance of periodontal maintenance for implant success.

These referenced publications include long-term outcome studies, reviews of immediate and early loading protocols, histologic and clinical studies of membrane-assisted bone regeneration, and AAP position papers on implant placement, bone augmentation, and periodontal maintenance that underpin the guideline's recommendations.

Background and definitions

Purpose: The guideline sets standards for the placement of dental implant bodies (fixtures) and describes the plan's review process to ensure requested services meet generally accepted standards of dental practice. It outlines required documentation and imaging (including dated, properly oriented diagnostic full mouth, panoramic, and/or other radiographs that document bone levels and quality and that show all existing and missing teeth in both arches) and lists clinical situations and patient-specific qualifiers that may justify implant placement.

The guideline is intended to standardize utilization review decisions by referencing generally accepted standards of dental practice (peer-reviewed evidence, specialty society recommendations, and expert views). As noted elsewhere in the document, whether a specific implant service is a covered benefit depends on the member's contract.

Implant Body (Fixture) Guideline Key Facts

Policy guideline ID1

Enumerated criteria items9

Referenced CDT codes (count)10

Definition: Generally accepted standards of dental practiceStandards that are based on credible scientific evidence published in peer-reviewed dental literature; specialty society recommendations/criteria; the views of recognized dentists practicing in the relevant clinical area; and any other relevant factors from credible sources.

Policy Summary

PayerAnthem

PolicyImplant Body (Fixture) Guideline

Policy CodePolicy 06-101

Change TypeRevised

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Implant Body (Fixture) Guideline

Policy overview

Clinical criteria for considering implant placement

Required documentation & utilization review actions

Relevant procedure codes (informational)

Supporting evidence and references

Background and definitions

Document revision history