CurrentAnthemPolicy 06-701

Abutment Crowns and Fixed Partial Dentures

Policy governing coverage criteria, documentation, and coding for abutment crowns and fixed partial dentures (bridges) for Anthem dental plans; affects providers submitting claims for replacement of missing teeth and related indirect restorations.

Policy Summary

PayerAnthem

PolicyAbutment Crowns and Fixed Partial Dentures

Policy CodePolicy 06-701

Change TypeNo material change

Effective DateJan 1, 2021

Next Review Date

Key ActionProvide recent, dated pretreatment radiographs and supporting diagnostic documentation including current 6‑point periodontal charting before benefit determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥50%Coronal loss threshold

6-pointPeriodontal charting

D6210-D6794CDT code range

NCApplicable state

Coverage Criteria for Abutment Crowns and Fixed Partial Dentures

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Structural integrity: Anterior abutment must demonstrate significant loss of coronal tooth structure (50% or more) and/or involvement of one or both incisal angles; posterior abutment must demonstrate significant missing tooth structure (50% or more), large restorations compromising function, or undermined cusps (one or more cusps) with compromised marginal ridges.50%

See criteria items 1-2 [[chunk 5]]

Endodontic status: No placement of an indirect restoration on a tooth with untreated or unresolved periapical or periradicular pathology, unresolved carious lesion in close proximity to the pulp without planned endodontic therapy, grossly overextended or underfilled obturations, or internal/external resorption; follow Dental Policy 03-001 Endodontic Therapy.

See criteria items 6-7 and Dental Policy 03-001 [[chunk 6]]

Periodontal health: Teeth must not demonstrate uncontrolled or untreated periodontal disease; loss of supporting bone including furcation may preclude benefit unless definitive periodontal therapy and maintenance are documented. A current dated 6‑point periodontal chart and periodontal history may be required prior to benefit determination.6-point chart

See criteria item 4 [[chunk 5]]

Clinical indications for replacement: Replacement for teeth fractured from external blunt trauma should be referred first to medical/health plan; fractures must involve missing tooth structure extending into dentin to be considered. Other indications (congenitally missing teeth, pathologic disorder resulting in extraction) are reviewed per criteria.

See criteria item 3 and related replacement guidance [[chunk 5,7]]

Prosthesis limitations and fabrication rules: Number of pontics must not exceed normal complement; fixed partial dentures fabricated to close spaces where no natural tooth is missing are not benefitted; insufficient space for a pontic is not benefitted; fixed partial dentures supported by inlay abutments are not covered; cantilever rules apply (anterior cantilever allowed with cuspid abutment replacing lateral incisor; posterior cantilever limited to one pontic supported by two abutments that meet stand‑alone crown requirements).

See criteria items 19-23 [[chunk 8]]

Missing tooth clause and alternate benefit rules

Missing tooth clause applies: If the group plan includes a missing tooth clause, there is no benefit for replacement of teeth that were missing prior to the member's effective date or were removed and not replaced prior to coverage; abutment teeth are still reviewed on their own merit.

See criteria items 12-13 [[chunk 7]]

Alternate benefit for multiple missing teeth: For plans without a missing tooth clause: if fewer than three teeth are missing in the arch, appropriateness of a fixed partial denture will be determined; if three or more teeth are missing in the arch, an alternate benefit of a removable partial denture may apply depending on the contract. Abutment teeth are reviewed on their own merit in either case.3 teeth

See criteria item 14 [[chunk 7]]

Not covered / exclusions

Cosmetic or non‑supported indications: Fixed partial dentures placed for occlusal alterations, changes in vertical dimension, treatment of TMD/craniomandibular disorders, correction of developmental or congenital defects (unless group contract indicates coverage), splinting routinely not covered, and replacements solely for discoloration or cosmetic defects are not benefitted.

See criteria items 11,18,25 and related exclusions [[chunk 7,8,9]]

Wear-related indications: Abutment crowns or fixed partial dentures placed to repair complications from wear, attrition, abrasion, erosion, or abfraction are not a covered benefit according to most group contracts.

See criteria item 5 [[chunk 5]]

Combination prostheses: Tooth‑implant supported fixed partial dentures will not be considered for benefits based on evidence of lower survival rates compared with solely implant‑supported or solely tooth‑supported prostheses.

See criteria item 23 [[chunk 8]]

Splinting of teeth by abutment crowns is routinely not a covered benefit unless the group contract explicitly indicates coverage. When splinting is requested, each additional crown abutment will be reviewed on its own merit and splinted crowns must be coded as retainer crowns. Fixed partial dentures supported by inlay abutment restorations are not a covered benefit. Cantilever rules and pontic limitations apply as described in policy (anterior cantilevers may be allowed in limited circumstances; posterior cantilevers are restricted to a single pontic supported by two abutments that each meet stand‑alone crown requirements). If one abutment for a fixed partial denture is denied, the entire fixed partial denture may be denied.

Existing fixed partial dentures that are discolored, misshapen, or have compromised cosmetics do not qualify for coverage as an indirect restoration. Benefits will not be considered for replacements unless there is documented recurrent caries, fracture, or a defective restoration that supports the need for replacement. Additionally, fixed partial dentures placed to address wear-related issues (wear, attrition, abrasion, erosion or abfraction) or to close contacts not caused by caries or fracture are generally not a covered benefit according to most group contracts.

Coding: CDT and Diagnosis Codes

Example CDT Codes (pontics, retainers, crowns)CDT

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

1–10 of 25

1/3

Additional CDT Codes (retainer crowns)CDT

D6782	Retainer Crown - ¾ cast noble metal
D6783	Retainer Crown - ¾ porcelain/ceramic
D6790	Retainer Crown - full cast high noble metal
D6791	Retainer Crown - full cast predominantly base metal
D6792	Retainer Crown - full cast noble metal
D6794	Retainer Crown - titanium

Diagnosis codesICD-10

ICD-10 CM

Diagnoses for dental diseases and conditions - see current CDT code book

Structural loss threshold for indirect abutment consideration

Structural loss thresholdAnterior or posterior abutment must demonstrate significant loss of coronal tooth structure: 50% or more

Anterior specificAnterior abutment: 50% or more coronal tooth structure loss and/or involvement of one or both incisal angles

Posterior specificPosterior abutment: 50% or more missing tooth structure, large restorations compromising function, or undermined cusps with compromised marginal ridges

Provider Requirements, Documentation, and Denial Triggers

Prior Authorization

Prior diagnostic documentation required

Prior diagnostic documentation is required before benefit determination for indirect restorations (including abutment crowns and fixed partial dentures). Recent, dated, properly identified pretreatment diagnostic radiographic images that include the radiographic apex must be submitted. When radiographs do not clearly demonstrate the condition, additional diagnostic information such as intraoral photographs and clinical chart notes stating the rationale for indirect restoration coverage must accompany the imaging.

Must include recent, dated, properly identified pretreatment diagnostic radiographic image(s) that include the radiographic apex.
If radiographic images are not definitive, submit intraoral photographs and clinical chart notes with rationale for indirect restoration coverage.

Documentation Required

Required documentation

Required documentation may include clinical chart notes, intra-oral photographs, current dated 6‑point periodontal charting, and history of periodontal therapy. The current periodontal status and history of periodontal therapy, presence of tooth mobility, and continuous maintenance therapy may be requested prior to benefit determination. Adjunctive documentation should demonstrate coronal tooth structure loss, restorability, endodontic status, and any periodontal therapy performed.

Clinical chart notes documenting presenting condition and rationale for indirect restoration.
Intra-oral photographs of the affected tooth/teeth when radiographs are insufficient.
Current dated 6‑point periodontal charting as described by the ADA and AAP when requested.
History and documentation of definitive periodontal therapy and maintenance, if periodontal disease was present.
Radiographic evidence of endodontic status; unresolved periapical/periradicular pathology or internal/external resorption may preclude benefit.
For primary teeth in adult dentition, radiographs must show intact root structure, adequate periodontal support, and no permanent successor or unlikely eruption.

Documentation Required

Alternate benefit considered

An alternate benefit (contract dependent) such as a removable partial denture may be considered when replacement of missing teeth or application of a missing tooth clause applies. When an alternate benefit is applied, abutment teeth are reviewed on their own merit and frequency limits or missing-tooth clause rules may result in denials.

If plan includes a missing tooth clause and the missing teeth were extracted and not replaced prior to coverage, there is no benefit for replacement with a fixed partial denture; abutment teeth still reviewed independently.
For plans without a missing tooth clause: if fewer than three teeth are missing, appropriateness of the fixed partial denture as a whole will be determined; if three or more teeth are missing, an alternate benefit of a removable partial denture may be contract dependent.
Application of an alternate benefit or missing tooth clause may result in frequency limitation denials or missing-tooth clause denials.

Background

Fixed partial dentures (bridges) and abutment crowns restore function by replacing missing teeth in a dental arch. For an abutment tooth to be considered on its own merit, an anterior abutment must demonstrate significant coronal tooth structure loss of 50% or more and/or involvement of one or both incisal angles; a posterior abutment must demonstrate significant missing tooth structure of 50% or more, large restorations that compromise function, or undermined cusps with compromised marginal ridges. Periodontal health is essential—teeth with uncontrolled or untreated periodontal disease, radiographic bone loss including furcation involvement, or poor periodontal status may not be considered for indirect restoration placement unless definitive periodontal therapy and maintenance have been documented. A current, dated 6‑point periodontal chart and periodontal history may be requested as part of benefit determination.

Policy Summary

PayerAnthem

PolicyAbutment Crowns and Fixed Partial Dentures

Policy CodePolicy 06-701

Change TypeNo material change

Effective DateJan 1, 2021

Next Review Date

Key ActionProvide recent, dated pretreatment radiographs and supporting diagnostic documentation including current 6‑point periodontal charting before benefit determination.

SourceLink

On This Page

OpenPayer

Abutment Crowns and Fixed Partial Dentures

Coverage Criteria for Abutment Crowns and Fixed Partial Dentures

Coding: CDT and Diagnosis Codes

Provider Requirements, Documentation, and Denial Triggers

Background

Definitions and Standards