CurrentAnthemPolicy 06-101

Anthem_Implant_Body_Fixture_Guideline_06-101

Clinical guideline describing Anthem's review criteria for placement of dental implant bodies (fixtures), including indications, required evaluations, documentation, and coding information; used to determine medical/dental necessity for utilization review, subject to member contract benefits.

Policy Summary

PayerAnthem

PolicyAnthem_Implant_Body_Fixture_Guideline_06-101

Policy CodePolicy 06-101

Change TypeRevised (no material clinical changes identified)

Effective DateJan 1, 2021

Next Review Date

Key ActionProvider must complete an evaluation of the functional occlusion of the entire dentition prior to implant placement.

SourceLink

POLICY UPDATE CHANGES

Policy status marked as Revised; revision history shows prior revisions (12/14/16, 02/05/18) but no clinical policy statement changes are specified in latest content.

8Key coverage criteria items

9CDT codes listed

Coverage Summary

Anthem performs review of dental implant placement to ensure services meet generally accepted standards of dental care and contractual requirements. A determination that a particular service is medically or dentally necessary does not constitute an indication or warranty that the service requested is a covered benefit payable by the dental plan; member contract benefits govern payment.

Clinical Indications / General Coverage Criteria

Dental implant placement may be considered appropriate when ALL of the following apply:

ALL of the following

Implants used to replace missing teeth resulting from accidental traumatic injuries to sound, natural teeth from an external blow; loss of teeth due to removal of pathologic disorders or unrestorable teeth; or congenitally missing teeth.
Evaluation of the functional occlusion of the entire dentition (mouth-oral cavity) completed prior to implant placement.
Dated, properly oriented, diagnostic full mouth, panoramic, and/or other appropriate radiographic images documenting bone levels and quality provided; panoramic or full mouth images must reveal all existing and missing teeth in both upper and lower arches.
Comprehensive treatment plan (may be requested) including periodontal status; may include documentation of history of definitive periodontal treatment including maintenance for remaining teeth.
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 adjacent teeth.
A patient's documented sensitivity (allergy) to denture restorative materials may qualify for implant placement if documented by physician and dental provider letters of medical/dental necessity and copy of laboratory analysis of the allergy.
Documented history of failed corrective procedures may qualify for implant placement when supported by a letter of dental necessity from the treating provider and appropriate radiographic evidence.
Immediate placement of a dental implant body (fixture) in a tooth extraction site is an acceptable procedure.

Exclusions / Not appropriate

Replacement of multiple teeth by dental implants in the same arch is not appropriate when other less costly dental services can adequately restore occlusion to function, unless specified by group contract.
Implant placement is generally not considered for correction of developmental or congenital defects (congenitally missing teeth) unless covered by group contract.

Coding (informational)

CDT codes (informational)mixed

D6010	surgical placement of implant body (fixture): endosteal implant
D6011	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
D6100	implant removal, by report
D7993	surgical placement of craniofacial implant extra oral
D7994	surgical placement: zygomatic implant

ICD-10-CM diagnoses (informational)ICD-10

No codes listed

Provider Actions & Documentation Requirements

Documentation Required

Pre-placement functional occlusion evaluation

Provider must complete an evaluation of the functional occlusion of the entire dentition prior to implant placement.

Documentation Required

Radiographic documentation required

Provider must supply dated, properly oriented diagnostic full mouth, panoramic, and/or other radiographic images documenting bone levels and quality; panoramic or full mouth images must reveal all existing and missing teeth in both arches.

Documentation Required

Comprehensive treatment plan and periodontal documentation

A comprehensive treatment plan including periodontal status and documentation of definitive periodontal treatment and maintenance may be requested.

Documentation Required

Allergy qualification documentation

If sensitivity to denture materials is the basis for implant placement, provider must supply physician and dental letters of medical/dental necessity and laboratory analysis of the allergy.

Documentation Required

Failed corrective procedures documentation

If implant placement is due to failed corrective procedures, provider must supply a letter of dental necessity and appropriate radiographic evidence.

Denial Risk

Potential non-coverage for multiple-tooth replacement when less costly alternatives exist

Replacement of multiple teeth in the same arch by implants may be considered not appropriate and subject to non-coverage if less costly dental services can adequately restore function, unless group contract specifies otherwise.

Background & Definitions

Anthem performs review of dental implant placement to ensure services meet generally accepted standards of dental care and contractual requirements. For dental purposes, "generally accepted standards of dental practice" are defined as standards based on credible scientific evidence published in peer-reviewed dental literature and specialty society recommendations recognized by the practicing dental community.

The conclusion that a particular service is medically or dentally necessary does not constitute an indication or warranty that the service requested is a covered benefit payable by the dental plan; member contract benefits govern payment.

Definitions

Generally accepted standards of dental practiceStandards based on credible scientific evidence published in peer‑reviewed dental literature and specialty society recommendations recognized by the practicing dental community.

Publish Date: 01/01/2021. The guideline references multiple peer-reviewed dental studies and specialty society documents (examples and full citations are listed in the policy references).

References listed include long-term clinical outcome studies, reviews on immediate and early loading protocols, and American Academy of Periodontology / American Dental Association publications that inform placement and management of dental implants.

Revision History

Revised (most recent)policy_revisionLatest

Policy status marked as Revised; latest document header indicates 'Status: Revised' and publish date 01/01/2021 with last review 12/05/2020.

02/05/2018policy_revision

Prior revision recorded on 02/05/18 (noted in revision history).

12/14/2016policy_revision

Prior revision recorded on 12/14/16 (initial version/revision history entry).

Policy Summary

PayerAnthem

PolicyAnthem_Implant_Body_Fixture_Guideline_06-101

Policy CodePolicy 06-101

Change TypeRevised (no material clinical changes identified)

Effective DateJan 1, 2021

Next Review Date

Key ActionProvider must complete an evaluation of the functional occlusion of the entire dentition prior to implant placement.

SourceLink

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