CurrentAnthemPolicy 06-701

Retainer Crowns and Fixed Partial Dentures

Defines clinical indications, documentation requirements, and coverage criteria for retainer crowns and fixed partial dentures (bridges and pontics) including exclusions, contract-dependent provisions (missing tooth clause, age limits), and CDT codes applicable to benefits determination.

Policy Summary

PayerAnthem

PolicyRetainer Crowns and Fixed Partial Dentures

Policy CodePolicy 06-701

Change TypeRevised (annual reviews noted)

Effective DateJan 1, 2024

Next Review Date

Key ActionProviders must submit current (within 12 months) dated diagnostic pretreatment radiographic images including the radiographic apex; may also be required to submit clinical chart notes, intra-oral photos, 6-point periodontal charting, and periodontal therapy history.

SourceLink

POLICY UPDATE CHANGES

Document shows revisions with annual reviews and committee review entries through 11/01/2023.

multipleCDT codes listed

conditionalCoverage status

contract-dependentMissing Tooth Clause impact

Coverage Summary

This policy defines clinical indications and documentation standards for determining the dental medical necessity of retainer crowns and fixed partial dentures (bridges and pontics), using generally accepted standards of dental practice and contract precedence. The policy stance is mixed/conditional: treatments may be appropriate when criteria are met but determinations are subject to plan contract rules. A determination that a service is medically or dentally necessary does not guarantee that the service is a covered benefit under a member’s specific plan. Additionally, the Missing Tooth Clause (MTC) and other contract provisions may restrict benefit eligibility and are contract-dependent.

Medical Necessity Criteria and Conditions

General Coverage Criteria

Covered when ALL of the following are met:

Clinical indications for replacement: Replacement of missing teeth via retainer crowns and fixed partial dentures may be appropriate when resulting from accidental traumatic injuries, pathologic disorder resulting in extraction, congenitally missing teeth, or congenital disorders resulting in extraction.
Retainer tooth condition: Retainer teeth supporting the fixed partial denture must exhibit periodontal and endodontic health and be aligned to direct forces along the long axis of the teeth.
Primary tooth in adult dentition: For a primary tooth within an adult dentition to qualify, radiographic images must show intact root structure, adequate periodontal support, no active periodontal disease, occlusal function with an opposing tooth, and no permanent tooth successor or unlikely eruption.
Anterior retainer indication: An anterior retainer tooth must demonstrate significant loss of coronal tooth structure due to caries, fracture, defective restoration and/or involvement of one or both incisal angles.
Posterior retainer indication: A posterior retainer tooth must demonstrate significant missing tooth structure due to caries, fracture, defective restoration, large restorations that compromise function, or loss of support for cusps where cusps are undermined with compromised marginal ridges.
Delivery date definition: Placement/delivery date of an indirect restoration is the date of initial cementation or bonding regardless of cement type.
Radiographic documentation: Current (within 12 months), dated, diagnostic pretreatment radiographic images that include the radiographic apex must be submitted; clinical chart notes, intra-oral photographs, current dated 6-point periodontal charting, and history of periodontal therapy may also be required.within 12 months
When radiographs insufficient: When radiographs are not sufficient to evaluate coverage, accompanying intraoral photographs and clinical chart notes explaining rationale are required.

Endodontic and Pulpal Conditions

Indirect restorations will be reviewed against endodontic status; ALL must be satisfied:

Periapical pathology: Placement of an indirect restoration on a tooth with untreated or unresolved periapical or periradicular pathology will not be considered for benefit.
See Dental Policy 03-001 Endodontic Therapy
Carious lesion near pulp: Placement on a tooth with an unresolved carious lesion in close proximity to the pulp chamber without planned endodontic therapy will not be considered for benefit.
See Dental Policy 03-001 Endodontic Therapy
Internal/external resorption: Placement on a tooth with internal or external resorption may not be considered for benefit.
See Dental Policy 03-001 Endodontic Therapy

Periodontal and Support Considerations

Benefit excluded or conditional when ANY of the following present unless corrected:

Uncontrolled periodontal disease: Teeth demonstrating uncontrolled or untreated periodontal disease (radiographic or periodontal charting evidence), loss of supporting bone including furcation, unless definitive periodontal therapy and maintenance have been performed.
Current dated 6-point periodontal chart may be required
Subgingival/sub-osseous caries: Teeth with subgingival/sub-osseous caries that compromise supracrestal tissue attachment without addressing periodontal considerations will not be considered.
Caries into furcation: Teeth with caries into the furcation will not be considered.
Unfavorable crown-to-root ratios (poorer than 1:1) require full mouth assessment and may affect benefit determination.

Special Conditions / Additional Rules

Metal allergy documentation: Replacement due to metal allergy/sensitivity will be considered only with submission of documentation by a physician and associated allergy report.
Temporary restoration: Temporary/provisional retainer crown/fixed partial denture is considered a component part of the final restoration.
Subgingival caries restriction: Fixed partial dentures are not benefitted when retainers exhibit subgingival/sub-osseous caries compromising supracrestal attachment without addressing periodontal issues.
Insufficient space for pontic: When there is insufficient space for a pontic, the pontic will not be benefitted.

Exclusions / Not Covered

The following are NOT covered:

Wear-related repairs not covered: Retainer crowns/fixed partial dentures placed for repair of complications from wear, attrition, abrasion, erosion or abfraction are not a covered benefit according to most group contracts.
Occlusal alterations/TMD: Fixed partial dentures placed for occlusal alterations, changes in vertical dimension, treatment of TMD or craniomandibular disorders are not covered.
Inlay-retained FPDs not covered: Fixed partial dentures supported by inlay retainer restorations are not a covered benefit.
Tooth-implant supported FPDs not covered: Tooth-implant supported fixed partial dentures will not be considered for benefits.
Developmental/congenital corrections not covered: Fixed partial dentures placed for correction of developmental or congenital defects (congenitally missing teeth, unerupted teeth, spacing due to migration/drifting) are not covered unless group contract indicates coverage.
Pontics without missing tooth: Pontics fabricated for closing spaces where there is no missing natural tooth are not benefitted.
Insufficient space for pontic: Pontics will not be benefited where there is insufficient space for a pontic.
Cosmetic issues not covered: Existing fixed partial dentures that are discolored, misshapen or have compromised cosmetics do not qualify for indirect restoration coverage.
Closure of contacts not covered: Fixed partial dentures are not covered when placed for closure of contacts unless caused by caries, tooth fracture, or defective restoration.
Replacement of existing FPD limited: Benefits are not available for replacement of an existing fixed partial denture unless supported by recurrent caries, fracture, or defective restoration.
Splinting not routinely covered: Splinting of teeth by retainer crowns is routinely not a covered benefit unless group contract indicates coverage; each additional retainer reviewed on its own merit.

Missing Tooth Clause (MTC) & Plan-Dependent Rules

Missing Tooth Clause (MTC) and Plan-Dependent Rules

Coverage depends on plan contract terms:

MTC applies to missing teeth prior to coverage: For plans that include an MTC, there is no benefit for replacement of teeth missing prior to the member's plan effective date; MTC does not apply to replacement prosthetics. Pontics designed to replace missing teeth will deny under MTC and retainers reviewed on their merit.
Plans without MTC and tooth count: For plans that do NOT include an MTC and fewer than three teeth are missing in the arch, appropriateness of the fixed partial denture will be determined; if three or more teeth are missing, an alternate benefit of a removable partial denture may apply depending on contract.
Denial of entire FPD if retainer denied: If one retainer is denied, the entire fixed partial denture may be denied.
Age limits: Age limitations for fixed partial dentures are group contract dependent.
Removable partial denture in same arch: Pontics for a fixed partial denture may not be benefitted where a removable partial denture exists in the same arch; retainers will be reviewed on their own merit.

Contract terms such as the Missing Tooth Clause (MTC), alternate benefits for multiple missing teeth, and group-specific age limits interact with medical necessity determinations: when an MTC applies, pontics replacing teeth missing prior to plan effective date will deny while retainers are reviewed on their own merit; plans without an MTC may apply an alternate removable partial denture benefit when ≥3 teeth are missing. Because coverage decisions are contract-driven, denial of one retainer can result in denial of the entire fixed partial denture.

Provider Actions and Requirements

Documentation Required

Submit diagnostic images and records

Submit current (within 12 months), dated, diagnostic pretreatment radiographic images that include the radiographic apex. Also provide clinical chart notes, intra-oral photographs, current dated 6‑point periodontal charting, and history of periodontal therapy when requested to support benefit determination for retainer crowns and fixed partial dentures.

Dated diagnostic pretreatment radiograph (within 12 months) including the radiographic apex
Clinical chart notes
Intra-oral photographs
Current dated 6‑point periodontal charting
History of periodontal therapy

Documentation Required

Provide adjunctive diagnostic information when radiographs insufficient

When the radiographic image does not clearly demonstrate the need for an indirect restoration, submit additional diagnostic information such as intraoral photographs of the affected tooth/teeth and clinical chart notes stating the rationale for coverage.

Prior Authorization

Benefit determination subject to contract terms and review

Coverage and payment are determined by the member's contract in effect at the time of service. Plans that include a Missing Tooth Clause (MTC) deny benefit for replacement of teeth missing prior to the plan effective date (MTC does not apply to replacement prosthetics). For plans without an MTC, if fewer than three teeth are missing the appropriateness of a fixed partial denture will be determined; if three or more teeth are missing an alternate benefit (removable partial denture) may apply depending on contract. Frequency limits, alternate benefits, and review of retainers on their own merit may affect benefit decisions.

Denial Risk

Incomplete service without delivery

If the patient does not return for delivery (initial cementation or bonding) the service is considered incomplete and no benefit is available.

Documentation Required

Metal allergy replacement documentation

Replacement of retainers for metal allergy or sensitivity will be considered only when physician documentation and the associated allergy report are submitted to support the request.

Physician documentation supporting metal allergy/sensitivity
Associated allergy report

Background and Evidence

Background: This policy provides guidance for evaluating dental medical necessity for retainer crowns and fixed partial dentures, emphasizing generally accepted standards of dental practice, required documentation (including current dated diagnostic pretreatment radiographs within 12 months), and that federal, state, and contract language take precedence. It reiterates that a finding of medical necessity does not guarantee that a service will be a covered benefit under the member’s plan and that plan contract provisions (for example, the MTC) govern final benefit determination.

References: American College of Prosthodontists (ACP) Parameters of Care; CDT 2024 (Current Dental Terminology); key prosthodontics and treatment planning texts (for example, Rosenstiel, Nesbit/Stefanac).

Other conditional statements

Other conditional statements:

Metal allergy replacement: Replacement due to metal allergy/sensitivity will be considered only with submission of documentation by a physician and associated allergy report.
Temporary is component: Temporary/provisional retainer crown/fixed partial denture is considered a component part of the final restoration.
Subgingival caries repeat: Fixed partial dentures are not benefitted when retainers exhibit subgingival/sub-osseous caries compromising supracrestal attachment without addressing periodontal considerations.
Insufficient pontic space repeat: When there is insufficient space for a pontic, the pontic will not be benefitted.
Posterior cantilever specifics: Posterior cantilever fixed partial dentures: only one cantilever pontic may be allowable and two retainers are necessary to support a single pontic; periodontal health and endodontic status of retainers must be considered.
Anterior cantilever allowance: Anterior cantilever fixed partial dentures where cuspids are retainers replacing lateral incisors may be benefited.

D6210	Pontic cast high noble metal
D6211	Pontic - cast predominantly base metal
D6212	Pontic cast noble metal
D6214	Pontic titanium
D6240	Pontic porcelain fused to high noble metal
D6241	Pontic - porcelain fused to predominantly base metal
D6242	Pontic - porcelain fused to noble metal
D6243	Pontic porcelain fused to titanium and titanium alloys
D6245	Pontic porcelain/ceramic
D6250	Pontic resin with high noble metal

OpenPayer

Retainer Crowns and Fixed Partial Dentures

Coverage Summary

Medical Necessity Criteria and Conditions

Exclusions / Not Covered

Missing Tooth Clause (MTC) & Plan-Dependent Rules

CDT Codes (examples)

Provider Actions and Requirements

Background and Evidence

Definitions

Revision History

Term	Definition
Missing Tooth Clause (MTC)
Contract provision denying benefit for replacement of teeth missing prior to the member's plan effective date; does not apply to replacement prosthetics.
Delivery date
Considered the date of initial cementation or bonding of the indirect restoration regardless of cement type.