CurrentAnthemPolicy 06-104

Implant/Abutment Supported Removable Prosthetics

Defines clinical indications, documentation and coding guidance for implant/abutment supported removable dental prosthetics and the situations in which the plan will review them; applies to providers rendering dental implant/abutment supported removable prosthetics for Anthem members.

Policy Summary

PayerAnthem

PolicyImplant/Abutment Supported Removable Prosthetics

Policy CodePolicy 06-104

Change TypeNo material changes

Effective Dateas written

Next Review DateN/A

Key ActionObtain current (within 12 months) dated diagnostic pretreatment full mouth radiographic imaging and documentation of implant stability and prior corrective procedures when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsrequired recency for full mouth pretreatment radiographic imaging

D6055, D6110-D6113, D6090example CDT codes listed

01/01/2024policy publish date

10/25/2023last review date

Coverage Criteria

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Medically necessary coverage criteria

Covered when any of the following clinical indications apply and documentation requirements are met:

Clinical indications: Implant/abutment supported removable prosthetics may be considered appropriate to replace missing teeth resulting from: accidental traumatic injuries to sound, natural teeth resulting in extraction; a pathologic disorder resulting in extraction; congenitally missing teeth; or congenital disorders of teeth resulting in extraction.

Supported by chunk 2

Documentation and prerequisites: Current (within 12 months), dated, diagnostic, pretreatment full mouth radiographic imaging is required; implant body must be stable per dental clinical policy #06-101; if inability to wear a removable appliance due to limited retention is cited, provide a letter of dental necessity, appropriate radiographic evidence, and a history of failed corrective procedures; repair or replacement requires a detailed narrative and/or chart notes.

Supported by chunk 6

Administrative and benefit considerations: Claims for replacement of missing teeth due to external blow or blunt trauma must first be referred to the member's medical plan; delivery date is considered the date of delivery depending on provider contract; temporary/provisional prosthetics are considered inclusive with the final restoration; replacement for aesthetic reasons is not a covered benefit.

Supported by chunk 6

Replacement of implant/abutment supported removable prosthetics for aesthetic reasons is explicitly excluded and is not a covered benefit under this policy. This exclusion means prosthetic replacement done solely to improve appearance, without meeting the medical or documentation criteria described elsewhere in the policy, will be denied as not covered.

A determination that a service is medically or dentally necessary does not automatically guarantee it is a covered, payable benefit. Coverage and payment are contract dependent; inclusion of procedure codes in the policy or coding section is informational and does not imply member coverage or provider reimbursement. Verify the member’s contract benefits and any prior authorization requirements before proceeding.

Provider Actions & Documentation Requirements

Denial Risk

Coverage conditional on contract and standards

Coverage for implant/abutment supported removable prosthetics is conditional on the member's benefit contract and whether services meet generally accepted standards of dental care. Even if a service is clinically necessary, it may be denied if it is not a covered benefit under the subscriber's contract or does not meet accepted standards and plan criteria.

Denial may occur if the service is not a covered benefit under the member's contract
Services must meet generally accepted standards of dental care and plan criteria

Billing Rule

Delivery and incomplete service notes

If the subscriber/patient does not return for delivery of the prosthetic, the service is considered incomplete and no benefit is payable. The delivery date noted by the provider is considered the date of service and should be used for billing and benefit determination, subject to the provider contract.

No benefit if the subscriber fails to return for delivery — service considered incomplete
Delivery date is considered the date of service (verify any contract-specific rules)

Documentation Required

Requirement to document prior corrective procedures before implants when limited retention is asserted

When limited retention is used as the justification for implant/abutment supported removable prosthetics, the provider must document prior corrective procedures and supply a letter of dental necessity supported by radiographic evidence. Records should include a history of failed corrective procedures demonstrating that less invasive options were attempted and were unsuccessful.

Document prior corrective procedures and their failure
Include a current dated diagnostic pretreatment full mouth radiographic imaging (within 12 months)
Provide a letter of dental necessity from the treating provider

Documentation Required

Required documentation

Required documentation for implant/abutment supported removable prosthetics includes current (within 12 months), dated, diagnostic pretreatment full mouth radiographic imaging and evidence of implant stability per clinical policy #06-101. Repair or replacement requests require detailed narrative and/or chart notes. Benefits remain contract dependent.

Current (<= 12 months) full mouth radiographic imaging
Documentation of implant stability per policy #06-101
Detailed narrative/chart notes for repair or replacement requests
Benefits are contract dependent — verify member contract

Background

Implant/abutment supported removable prosthetics are removable by design and are used to replace missing teeth resulting from trauma, pathologic conditions, or congenital absence. The plan reviews these services to ensure they meet generally accepted standards of dental care and the member’s contract. Clinical prerequisites include current (within 12 months) dated diagnostic pretreatment full mouth radiographic imaging and confirmation that the implant body is stable per dental clinical policy #06-101. If inability to wear a conventional removable appliance due to limited retention is cited, the provider must supply a letter of dental necessity, supporting radiographic evidence, and documentation of failed corrective procedures. Repair or replacement requests require detailed narrative or chart notes, and benefits remain contract dependent.

Definitions

Removable — definition

DefinitionAble to be taken out by the patient (as opposed to prosthetics that may only be removable by a dentist).

Who can removePatient can remove the prosthetic without dental assistance.

ContrastDiffers from implant/abutment supported removable prosthetic which may require a dentist to remove.

Implant/abutment supported removable prosthetic — definition

DefinitionA removable dental prosthetic supported by implants or abutments that may require a dentist to remove, rather than being removable by the patient.

SupportSupported by implants and/or abutments (implant/abutment supported).

RemovalMay only be removable by a dentist rather than by the patient.

D6055	Connecting bar - implant supported or abutment supported
D6110	Implant/abutment supported removable denture for edentulous arch - maxillary
D6111	Implant/abutment supported removable denture for edentulous arch - mandibular
D6112	Implant/abutment supported removable denture for partially edentulous arch - maxillary
D6113	Implant/abutment supported removable denture for partially edentulous arch - mandibular
D6090	Repair implant supported prosthesis, by report

OpenPayer

Implant/Abutment Supported Removable Prosthetics

Coverage Criteria

Coding and Billing Codes

Provider Actions & Documentation Requirements

Background

Definitions