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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield Maine implant coverage | Op…
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    CurrentBlue Cross Blue Shield - MainePolicy 06-001

    Implant/Abutment Supported Fixed Prosthetics - Crowns and Fixed Partial Dentures

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    Defines clinical indications, documentation and coverage criteria for dental implant- and abutment-supported crowns and fixed partial dentures for Blue Cross Blue Shield - Maine members; applies to dental providers submitting claims for implant prosthetics.

    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyImplant/Abutment Supported Fixed Prosthetics - Crowns and Fixed Partial Dentures
    Policy CodePolicy 06-001
    Change TypeNo material change
    Effective DateJan 1, 2025
    Last ReviewOct 29, 2024
    Next Review Date
    Key ActionInclude current (within 12 months), dated diagnostic preoperative radiographic images with authorization; if radiographs are not definitive, add intra-oral photos, treatment notes and a narrative.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsradiographic timeframe

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    May be NMNmultiple teeth same arch
    Excludedthird molar sites
    Inclusivetemporary restorations

    Coverage Criteria

    Initial coverage criteria

    Covered when ALL of the following are met (unless group contract specifies otherwise):

    Pre-procedure evaluation: A thorough dental evaluation, medical and dental history, full mouth imaging, and treatment plan completed prior to implant placement and restoration.
    Appropriate clinical indication: Missing teeth must be present and replacement is appropriate (e.g., missing due to accidental traumatic injury with extraction/avulsion, pathologic disorder resulting in extraction, congenitally missing teeth, or congenital disorders of teeth resulting in extraction). Claims for missing teeth resulting from accidental external injury should first be referred to the member's medical plan when applicable.
    Radiographic and diagnostic documentation: Current (within 12 months), dated, diagnostic preoperative radiographic images required; when radiographs are not definitive include intra‑oral photographs, patient treatment notes and a narrative explaining extraordinary circumstances.within 12 months
    Contract and alternate benefit considerations: Coverage is subject to member contract provisions (e.g., missing tooth clauses or alternate benefit provisions). When the plan contains a missing tooth clause or alternate benefit provision, an alternate benefit or no benefit for implant replacement may apply; verify contract terms prior to provision.
    Temporary restorations inclusive: Temporary/provisional implant/abutment supported crowns and fixed partial dentures are considered inclusive with the final restoration.

    Limitations and not medically necessary scenarios

    Not covered or limited in these situations:

    Not appropriate when teeth are not missing: Implant/abutment supported prosthetics are not appropriate where teeth are not missing, including replacement of third molars (implant placement/restoration for third molar sites is not a covered benefit; contract dependent).
    Multiple teeth in same arch may be NMN: Replacement of multiple teeth by implant-supported crowns or fixed partial dentures in the same arch is not medically necessary when less costly, professionally acceptable alternatives can restore occlusion and function (unless group contract specifies otherwise).
    Tooth-implant supported FPDs discouraged: Tooth‑implant supported fixed partial dentures may not be considered for benefits due to lower survival rates compared to solely implant‑supported or solely tooth‑supported fixed partial dentures.
    Aesthetic or contact closure reasons excluded: Replacement of implant/abutment supported prosthetics will not be considered solely for aesthetic reasons or for closure of contacts unless the prosthetic is defective.

    Implant placement and/or restoration is not a covered benefit for third molar sites when the member's contract includes that exclusion. This contract-dependent exclusion is referenced in the criteria that require evaluation of plan provisions (e.g., missing tooth clauses and alternate benefit rules) prior to treatment and states explicitly that implant placement/restoration for third molars is not covered.

    Replacement of implant/abutment supported prosthetics solely for aesthetic reasons or for closure of contacts will not be considered unless the prosthetic is defective. Documentation must demonstrate prosthetic defectiveness to support coverage in these situations.

    Replacement of multiple teeth in the same arch with implant-supported crowns or fixed partial dentures is not medically necessary when less costly professionally acceptable alternatives can adequately restore occlusion and function, unless the group contract specifically allows otherwise. Providers must review member contract provisions (including missing tooth and alternate benefit clauses) and consider alternate benefits before planning multiple-tooth implant restorations.

    Coding and Billing

    Applicable CDT Codes (informational)CDT
    D6010Surgical placement of implant body; endosteal implant.
    D6011Surgical access to an implant body (second stage implant surgery).
    D6013Surgical placement of mini implant.
    D6055Connecting bar implant or abutment supported.
    D6056Prefabricated abutment - includes modification and placement.
    D6057Custom fabricated abutment - includes placement.
    D6051Interim implant abutment placement.
    D6052Semi-precision attachment abutment.
    D6110Implant/abutment supported removable denture for edentulous arch - maxillary.
    D6111Implant/abutment supported removable denture for edentulous arch - mandibular.
    1–10 of 70
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    Provider Actions and Documentation Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for implant placement and prosthetic CDT codes. Verify member contract and group-specific requirements prior to scheduling. Failure to obtain prior authorization when required may result in claim denial or member liability.

    • Affected codes include CDT implant and prosthetic codes (e.g., D6010–D6199).
    • Confirm prior auth rules and submission requirements with the member’s contract/plan prior to service.
    Denial Risk

    Replacement for Non‑Missing Teeth — Denial Risk

    Replacement of teeth that are not missing — including third molars — is inappropriate and may be denied. Implant/abutment supported crowns and fixed partial dentures are intended to replace missing teeth only; replacement for non-missing teeth or solely for aesthetic reasons is not covered.

    • Replacement for teeth that are not missing (including third molars) may be denied.

    Background

    Dental implants are surgical components used to replace missing tooth/teeth and provide durable, long-term function. Implant/abutment supported crowns and fixed partial dentures are prosthetic restorations attached to implants and/or abutments to restore occlusion when teeth are missing due to accidental trauma, pathologic extraction, or congenital absence. Coverage for these services is subject to contract limitations and alternate benefit provisions and requires appropriate preoperative evaluation and documentation.

    Definitions

    Dental implant — definition
    DefinitionA surgical component used to replace a missing tooth or multiple teeth that mimics natural tooth structure and function.
    PurposeProvides a durable, long‑lasting solution to restore tooth form and function.
    Use casesReplaces one or more missing teeth due to trauma, pathology, or congenital absence.
    Relationship to prostheticsServes as the foundation for implant/abutment supported crowns and fixed partial dentures.
    Implant/Abutment Supported Crowns and Fixed Partial Dentures — definition
    DefinitionArtificial tooth or teeth attached to implants and/or abutments to replace missing teeth.
    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyImplant/Abutment Supported Fixed Prosthetics - Crowns and Fixed Partial Dentures
    Policy CodePolicy 06-001
    Change TypeNo material change
    Effective DateJan 1, 2025
    Last ReviewOct 29, 2024
    Next Review Date
    Key ActionInclude current (within 12 months), dated diagnostic preoperative radiographic images with authorization; if radiographs are not definitive, add intra-oral photos, treatment notes and a narrative.
    SourceLink
    On This Page
    Coverage CriteriaCoding and BillingProvider Actions and Documentation RequirementsBackgroundDefinitions
    Cantilever limitation: For cantilever implant/abutment supported fixed partial dentures, only one cantilever pontic may be an allowable benefit; peri‑implant health of retainers must be considered.
  1. Implant placement/restoration is not a covered benefit for third molar sites (contract dependent).
    2. Documentation Required

    Radiographic and Diagnostic Documentation

    Documentation must include current (within 12 months), dated diagnostic preoperative radiographic images. If radiographs do not clearly demonstrate necessity, provide intra-oral photographs, patient treatment notes, and a narrative explaining extraordinary circumstances.

    • Radiographs must be dated and taken within 12 months of implant placement.
    • When radiographs are inconclusive, include additional diagnostic information (intra‑oral photos, notes, narrative).
    Documentation Required

    Preoperative Evaluation and Treatment Planning

    A thorough dental evaluation must be completed prior to implant placement and restoration. This includes a comprehensive dental exam, complete medical and dental history, full‑mouth imaging, and a documented treatment plan.

    • Complete dental evaluation and treatment planning required before implant placement.
    • Document medical and dental history, full mouth imaging, and proposed restorative plan.
    Prior Authorization

    Missing Tooth Clause / Alternate Benefit — Check Member Contract

    When the plan contains a missing tooth clause or alternate benefit provision, verify contract language. If the plan contains a missing tooth clause there may be no benefit for implant/restorative replacement; if the plan does not contain the clause, an alternate benefit may be applied and a determination of necessity will be made.

    • Plans with a missing tooth clause: no benefit for replacement of missing teeth with implant/abutment supported restorations; implant placement/restoration not covered for third molar sites.
    • Plans without a missing tooth clause: carrier will determine medical necessity or apply alternate benefit per group contract.
    ComponentsIncludes crowns and fixed partial dentures that are supported by implants and/or abutments.
    IndicationUsed to restore occlusion and function when teeth are missing.
    VariationApplies regardless of number of missing teeth; prosthetic design depends on clinical need.