CurrentAnthemPolicy Guidelines #: 06-104

Implant Supported Removable Prosthetics

Clinical guideline describing when implant-supported removable dental prosthetics may be considered appropriate and the documentation/coding expectations for dental reviewers; applies to Anthem plans and affiliates where dental services are reviewed for medical/dental necessity.

Policy Summary

PayerAnthem

PolicyImplant Supported Removable Prosthetics

Policy CodePolicy Guidelines #: 06-104

Change TypeNo material changes

Effective Date01/01/2022

Next Review DateN/A

Key ActionSubmit current full mouth radiographic imaging and documentation of implant stability (per policy #06-101) with claims or prior authorization requests; include letters of dental necessity, supporting radiographs, and detailed narratives when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Number of explicit numbered criteria items

CDT 2022Coding edition referenced

01/01/2022Publish date

When Implant-Supported Removable Prosthetics May Be Appropriate

General Appropriateness / Clinical Indications

ANY of the following

Accidental traumatic injuries to sound, natural teeth from an external blow resulting in extraction
Pathologic disorder resulting in extraction
Congenitally missing teeth
Congenital disorders of teeth resulting in extraction

Documentation and imaging requirements

Services are subject to dental review and require the following:

ALL of the following

Current full mouth radiographic imaging is required
Implant body must be stable (see dental clinical policy #06-101)
Stability requirement referenced to separate policy 06-101

Accidental injury pathway

When missing teeth result from external trauma:

ALL of the following

Claims for replacement of missing teeth resulting from an external blow or blunt trauma must first be referred to the subscriber/employee's medical plan
Medical plan may cover replacement; dental review contingent on medical plan determination

Provisional prosthetics and delivery date

Operational coverage points

ALL of the following

Delivery date of dental implant supported removable prosthetics is considered the date of initial delivery, dependent on provider contract
A temporary or provisional dental implant removable prosthetic will be considered inclusive with the final restoration

Limited retention / inability to wear removable appliance

Condition qualifying a patient for implant-supported removable prosthetic placement

ALL of the following

Patient's inability to wear a removable appliance due to limited retention may qualify
Must be documented by a letter of dental necessity from treating provider, supported by appropriate radiographic evidence, and a history of failed corrective procedures

Repair or replacement

Requirements for repair or replacement claims

ALL of the following

Repair or replacement of implant supported removable prosthetics requires a detailed narrative and/or chart notes
Benefits are contract dependent

Relevant CDT and Diagnosis Codes

CDT codes (examples listed)CDT

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

DiagnosesICD-10

See CDT/ICD-10 CM

IDC-10 CM Diagnoses for Dental Diseases and Conditions — refer to current code books

What Providers Must Submit and When

Documentation Required

Radiographic documentation required

Submit current full mouth radiographic imaging with the claim or prior authorization request.

Documentation Required

Implant stability documentation

Document that the implant body is stable in accordance with dental clinical policy #06-101 when seeking coverage for implant-supported removable prosthetics.

Documentation Required

Letter of dental necessity for limited retention

When asserting a patient's inability to wear a removable appliance due to limited retention, include a letter of dental necessity from the treating provider supported by appropriate radiographic evidence and a history of failed corrective procedures.

Prior Authorization

Medical plan coordination for traumatic tooth loss

For missing teeth due to an external blow or blunt trauma, refer the claim to the member's medical plan prior to dental review and indicate the medical plan's determination in the dental submission.

Documentation Required

Narrative for repair/replacement

Provide a detailed narrative and/or chart notes to support requests for repair or replacement of implant-supported removable prosthetics; note that benefits are contract dependent.

Clinical and Administrative Context

This guideline defines implant-supported removable prosthetics (prosthetics that can be removed by the patient) and establishes review expectations to ensure dental services meet generally accepted standards of dental care and applicable contractual benefit rules. The plan performs review of these services because contracts may require that dental benefits be provided only when care meets accepted standards and is appropriate for the patient’s condition. The guideline further clarifies that a determination that a service is medically or dentally necessary does not automatically imply coverage under the dental plan or guarantee payment of the service.

Reviewers should expect claims and prior authorization requests to include appropriate documentation, including current full‑mouth radiographic imaging and demonstration of implant body stability (see Dental Clinical Policy #06-101). For cases of missing teeth due to an external blow or blunt trauma, the claim must first be referred to the member’s medical plan because most medical plans may cover replacement in those circumstances; the medical plan determination should be indicated when the dental review proceeds.

Operational points include that the delivery date for implant-supported removable prosthetics is typically considered the date of initial delivery (subject to provider contract), and that a temporary or provisional implant removable prosthetic is considered inclusive with the final restoration. Requests for coverage based on inability to wear a removable appliance due to limited retention must be supported by a letter of dental necessity, appropriate radiographs, and a history of failed corrective procedures. Repair or replacement requests require a detailed narrative and/or chart notes and remain contract dependent.

Key Term(s)

Definitions

TermRemovable

DefinitionAble to be taken out by the patient (as opposed to an implant-supported retrievable prosthetic which can only be taken out by a dentist).

Clinical distinction'Removable' refers to patient-removable prosthetics; implant-supported retrievable prosthetics require a dental professional for removal.

Policy Summary

PayerAnthem

PolicyImplant Supported Removable Prosthetics

Policy CodePolicy Guidelines #: 06-104

Change TypeNo material changes

Effective Date01/01/2022

Next Review DateN/A

SourceLink

On This Page

Implant Supported Removable Prosthetics

When Implant-Supported Removable Prosthetics May Be Appropriate

Relevant CDT and Diagnosis Codes

What Providers Must Submit and When

Clinical and Administrative Context

Key Term(s)

Policies to Read Alongside This Guideline