CurrentBlue Cross Blue Shield - MainePolicy 06-101

Implant Body (Fixture) Placement Coverage Criteria

Clinical guidelines governing when placement of dental implant bodies (fixtures) is considered appropriate for patients covered by the plan; intended for providers performing utilization review and dentists submitting implant placement for benefit determination.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyImplant Body (Fixture) Placement Coverage Criteria

Policy CodePolicy 06-101

Change TypeNo material change

Effective DateJan 1, 2022

Next Review Date

Key ActionSubmit prior review documentation including evaluation of functional occlusion and dated panoramic or full-mouth radiographs documenting bone levels and quality.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10CDT codes (informational)

01/01/2022Publish date

08/19/2021Last review

≥9Placement criteria

Coverage Criteria

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Pre-procedure evaluation: Prior to implant placement an evaluation of the functional occlusion of the entire dentition must be completed.

Provider must document functional occlusion assessment.

Imaging: Dated, properly oriented diagnostic full mouth, panoramic, and/or other appropriate radiographic images documenting bone levels and quality must be provided; panoramic or full mouth images must show all existing and missing teeth in upper and lower arches.

Radiographs required to document bone and dentition.

Treatment plan and periodontal status: A comprehensive treatment plan may be requested including periodontal status and documentation/history of definitive periodontal treatment and maintenance for remaining teeth.

May be requested by reviewer.

Single-tooth replacement: In the absence of multiple missing teeth and active infection, single tooth replacement by dental implant may be considered regardless of need for full crown coverage of adjacent teeth.

Benefits for implant placement for a second molar tooth are plan specific.

Immediate placement of a dental implant body in a tooth extraction site is an acceptable procedure.

Immediate placement permitted.

Inability to wear removable appliance: A patient's inability to wear a removable appliance due to limited retention may qualify for implant placement if documented by a letter of dental necessity, supported by radiographs, and history of failed corrective procedures.

Requires letter and supporting evidence.

Allergy to denture materials: Patient sensitivity (allergy) to denture restorative materials may qualify for implant placement if documented by physician and dental letters of medical/dental necessity and a laboratory analysis of the allergy.

Laboratory verification required.

Replacement of multiple teeth by dental implants in the same arch is not appropriate when other less costly dental services can adequately restore occlusion, unless a specific group contract provision states otherwise. The policy further notes that the prosthetic restoration of implants may be subject to alternate benefit plan provisions, so implant-based treatment for multiple adjacent missing teeth should be considered only after evaluating less costly, clinically acceptable alternatives and any contract limitations.

Services that do not meet generally accepted standards of dental practice — in type, frequency, extent, or effectiveness, or those provided primarily for convenience or cosmetic reasons — may be considered not medically necessary for plan payment. Additionally, more costly procedures will be subject to scrutiny when appropriate, less expensive alternatives exist; such services may be denied if they fail to meet accepted clinical standards or contractual coverage requirements.

Coding

CDT Codes (informational)CDT

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
D6050	surgical placement: transosteal implant
D6100	Surgical removal of implant body
D6198	Remove interim implant component/removal of implant component
D7993	Surgical placement of craniofacial implant extra oral
D7994	Surgical placement: zygomatic implant

Provider Actions & Documentation Requirements

Prior Authorization

Prior Review / Documentation Expectation

Prior review may be required for implant placement requests. The treating provider should submit documentation to allow the plan to determine whether the requested service meets generally accepted standards of dental care and contractual requirements for benefits.

Prior review/authorization may be required per group contract
Provide complete documentation at time of request to avoid delays

Denial Risk

Denial Risk Triggers

Services that do not meet generally accepted standards of dental care, lack required documentation, or are more costly than alternative treatments that would adequately restore function may be denied. Replacement of multiple teeth with implants in the same arch may be considered inappropriate when less costly options can adequately restore occlusion unless the group contract specifies otherwise.

Replacement of multiple teeth by implants may be denied when less costly alternatives can restore function
Requests lacking required documentation (see Documentation callout) are at higher risk for denial
Coverage determinations are subject to member contract provisions and may result in alternate benefit application

Documentation Required

Required Documentation

Providers must submit specific documentation prior to implant placement to support medical/dental necessity determinations.

Evaluation of the functional occlusion of the entire dentition completed prior to implant placement (dated and signed)
Dated, properly oriented diagnostic panoramic and/or full‑mouth radiographs or other appropriate imaging documenting bone levels and quality; images must show all existing and missing teeth in both arches
A comprehensive treatment plan, including periodontal status and history of definitive periodontal treatment and maintenance, when requested
When inability to wear a removable appliance is cited as justification: include a letter of dental necessity from the treating provider, supporting radiographs, and history of failed corrective procedures
When allergy/sensitivity to denture materials is cited: include physician and dental letters of medical/dental necessity and laboratory analysis documenting the allergy

Background

Dental implants are surgical fixtures placed to replace missing teeth resulting from trauma, extraction of diseased or unrestorable teeth, or congenitally missing teeth. Appropriate placement decisions require adherence to accepted clinical standards, including assessment of the patient’s overall dentition and functional occlusion, review of dated, properly oriented radiographs to document bone levels and quality, and consideration of periodontal status and prior definitive periodontal treatment where applicable. Implant therapy may include single-tooth replacement, immediate placement into extraction sites, or qualifying indications such as inability to wear a removable appliance or documented allergy to denture materials when supported by required documentation.

Definitions

Generally accepted standards of dental practice — definition and sources

DefinitionStandards based on credible scientific evidence published in peer-reviewed dental literature, specialty society recommendations/criteria, and the views of recognized dentists practicing in the relevant clinical area.

Sources of evidencePeer‑reviewed dental literature and credible scientific evidence recognized by the practicing dental community.

Specialty guidanceRecommendations and criteria from relevant dental specialty societies inform accepted standards of practice.

Expert opinionThe views of recognized dentists practicing in the relevant clinical area are used to interpret evidence and guide care.

Application to coverageServices must meet these standards and be no more costly than appropriate alternatives to be considered medically/dentally necessary under plan review.