CurrentAnthemPolicy 06-103

Management of Peri-Implant Defects

Defines clinical indications, diagnostic submission requirements, and treatment options for management of peri-implant defects for dental providers requesting review of services under the plan.

Policy Summary

PayerAnthem

PolicyManagement of Peri-Implant Defects

Policy CodePolicy 06-103

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionInclude a current (within 12 months) diagnostic pretreatment radiograph and clinical documentation when submitting services for review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6treatment modalities listed

D6101-D6103CDT procedure codes cited

12radiograph recency (months)

>5probing depth concern

Coverage Criteria

Medical necessity criteria for treatment of peri-implant defects

Covered when ALL of the following are met

Diagnosis: Clinical diagnosis of a peri-implant defect (peri-implantitis or peri-implant mucositis) based on clinical signs such as swelling, redness, bleeding on probing, increased probing depth (e.g., > 5 mm), suppuration, soft tissue attachment loss, implant mobility, percussion changes, occlusion findings, and radiographic evidence of bone loss.probing depth > 5 mm; radiographic bone loss

Radiographic examination is used to differentiate peri-implant mucositis from peri-implantitis.

Documentation: Submission includes current (within 12 months), dated, diagnostic pretreatment radiographic image(s) showing the complete implant; clinical chart notes; intra-oral photographs; current dated 6‑point periodontal charting including implant mobility; and history of periodontal therapy.radiograph within 12 months

These items may be required for review.

Policy Summary

PayerAnthem

PolicyManagement of Peri-Implant Defects

Policy CodePolicy 06-103

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionInclude a current (within 12 months) diagnostic pretreatment radiograph and clinical documentation when submitting services for review.

SourceLink

On This Page

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.

Acceptable treatment approaches: Treatment may be surgical or nonsurgical, including: 1) systemic antibiotics alone; 2) mechanical debridement (with or without systemic antibiotics); 3) mechanical debridement with or without localized drug delivery and chlorhexidine rinses; 4) mechanical debridement combined with LASER decontamination; 5) surgical debridement; and 6) surgical debridement with guided bone regeneration (GBR). Implant removal may be performed when indicated.

Selection depends on lesion severity and clinical judgment; focus on infection control, implant surface detoxification, and regeneration of lost support.

Coding

CDT codes citedmixed

D4245	Apically positioned flap.
D6100	Implant removal, by report.
D6101	Debridement of a peri-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure.
D6102	Debridement and osseous contouring of a peri-implant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure.
D6103	Bone graft for repair of peri-implant defect - not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration.
D6081	Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure.

Probing depth concern — threshold

Probing depth threshold indicating concern> 5 mm

Associated clinical signs at this depthBleeding on probing and/or suppuration

Interpretation noteDepths >5 mm with bleeding/suppuration suggest peri-implantitis rather than mucositis

Radiograph recency — required timeframe

Required radiograph recency for submissionWithin 12 months (current, dated diagnostic pretreatment radiograph)

Radiograph view requirementImage(s) must include the complete view of the implant

PurposeRadiographic exam used to differentiate peri-implant mucositis from peri-implantitis

Provider Actions & Documentation

Billing Rule

Procedure coding and review

Procedure coding and listed CDT codes are provided for informational purposes and may require review against the member's contract for coverage and payment determination. Inclusion of a code here does not guarantee member coverage or provider reimbursement; verify benefits and prior authorization requirements per the member's plan.

Affected codes include, but are not limited to: D4245, D6100, D6101, D6102, D6103, D6081
Confirm member contract for prior authorization and coverage rules before proceeding

Documentation Required

Required documentation

Submission for review must include current (within 12 months), dated, diagnostic pretreatment radiographic image(s) that show the complete implant. Additional documentation that may be required includes clinical chart notes, intra-oral photographs, current dated 6-point periodontal charting (including implant mobility), and history of periodontal therapy.

Radiographs: Current (≤12 months), dated, pretreatment images showing full implant
Clinical documentation: Chart notes and intra-oral photographs
Periodontal charting: Current dated 6-point probing including implant mobility
Treatment history: Prior periodontal therapy details

Denial Risk

Coverage contingent on contract standards

Services must meet the member's contract standards and generally accepted standards of dental care. Services that do not meet contract criteria or generally accepted standards may be deemed not medically or dentally necessary and therefore not covered.

Coverage determination is contingent on member contract language and clinical standards
Not all clinically appropriate services are covered benefits under every contract

Note

Unspecified provider-action callout

Provider-facing notes: some provider actions are unspecified in source and should be confirmed with the plan — e.g., prior authorization procedures, submission portals, and any site-specific billing instructions.

Confirm prior authorization requirements and submission method with the member's plan
Verify billing instructions and supporting documentation checklist before claim submission

Background

Peri-implant defects are inflammatory conditions affecting the soft and hard tissues surrounding osseointegrated dental implants. Clinical signs include swelling, redness, bleeding on probing, increased probing depth (for example, > 5 mm), suppuration, soft tissue attachment loss, implant mobility, and percussion changes. Microbiologically, peri-implant infections have similarities to periodontal disease. Radiographs are used to document and distinguish peri-implant mucositis from peri-implantitis and to identify radiographic bone loss; diagnostic images should be current (typically within 12 months) when submitted for review.

OpenPayer

Management of Peri-Implant Defects

Coverage Criteria

Coding

Provider Actions & Documentation

Background

Definitions