CurrentBlue Cross Blue Shield - MainePolicy 06-001

Implant Fixed Prosthetics - Crowns and Fixed Bridges

Governs review and medical/dental necessity determination for implant-supported crowns, abutment-supported crowns, and implant/abutment-supported fixed partial dentures for replacement of missing teeth for Blue Cross Blue Shield - Maine members.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyImplant Fixed Prosthetics - Crowns and Fixed Bridges

Policy CodePolicy 06-001

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review Date

Key ActionObtain a complete exam, treatment plan, and diagnostic imaging prior to implant placement and restoration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>30procedure codes referenced (CDT/D series)

12 monthsrequired imaging timeframe

Not coveredthird molar implants

Includedtemporary restorations

Coverage and Medical Necessity Criteria

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.

Primary coverage criteria: 1) The missing tooth being replaced by an implant-supported crown or implant/abutment-supported fixed partial denture is due to one of the following: accidental traumatic injury to a sound natural tooth (external blow resulting in extraction), a pathologic disorder resulting in extraction, congenitally missing teeth, or congenital disorders of teeth resulting in extraction;

See clinical indications for accepted standards of dental practice.

Pre-procedure evaluation: 2) Prior to implant placement and restoration, a thorough dental examination, medical and dental history, full mouth imaging, and a treatment plan have been completed;

A letter of dental necessity with radiographic evidence is required when inability to wear a removable appliance is cited.

Documentation: 3) Documentation includes diagnostic radiographic images within the preceding 12 months; when radiographs do not clearly justify necessity, additional diagnostic information (intra-oral photographs, patient treatment notes, and a narrative explaining extraordinary circumstances) must accompany the images;Diagnostic radiographs within the preceding 12 months

Required documentation for coverage.

Provisional restorations: 4) Temporary or provisional implant prostheses are considered inclusive with the final restoration;

Temporary/provisional restorations are included with final restoration.

Third molar exclusion: 5) Implant placement/restoration for third molar sites is not covered;

Replacement for third molars is not covered under this policy.

Allergy documentation: 6) Replacement due to metal allergy or sensitivity will be considered only upon submission of physician documentation with the associated allergy report;

See allergy documentation requirement.

Alternate benefit / plan provisions: 7) When less costly dental services can adequately restore occlusion, implant placement/restoration (particularly for replacement of multiple teeth in the same arch) may be denied or an alternate benefit applied per group contract or alternate benefit provisions; medical plan referral may be required for accidental injury claims;

Plan and group contract provisions may override criteria; medical plan may cover accidental injury related replacements.

Not appropriate / restricted scenarios

Situations considered NOT appropriate or limited:

Not appropriate / restricted scenarios: 1) Replacement when teeth are not missing, including replacement of third molars;

Implant placement/restoration is not a covered benefit for third molar sites.

Not appropriate / restricted scenarios: 2) Replacement of multiple teeth in the same arch with implant-supported restorations when other less costly dental services can adequately restore occlusion to function (unless group contract specifies otherwise);

Alternate benefit or least-cost alternative provisions may apply.

Not appropriate / restricted scenarios: 3) Tooth–implant supported fixed partial dentures may not be considered for benefits based on evidence showing lower survival rates compared with solely implant-supported or solely tooth-supported fixed partial dentures (this limitation is plan specific);

Plan-specific provision; benefits are contract dependent.

Implant placement or restoration is not a covered benefit for third molar sites. The policy also specifies that implant services are not appropriate when teeth are not missing; this explicitly includes replacement of third molars. These exclusions are plan- and contract-dependent, so group contract provisions and alternate benefit clauses should be checked as they may modify coverage determinations.

Documentation and pre-procedure requirements remain applicable even when exclusions are present: a thorough dental exam, medical and dental history, full mouth imaging, and a completed treatment plan are required prior to implant placement and restoration. When alternate benefit or missing-tooth clauses apply, the plan may deny implant coverage accordingly.

Replacement of multiple teeth in the same arch with implant-supported restorations is not medically necessary when other less costly dental services can adequately restore occlusion to function, unless the group contract specifies otherwise. Plans with alternate benefit provisions may apply a less costly option in place of implant restorations.

This limitation is contract-sensitive: when a group contract does not contain a missing-tooth clause or includes alternate benefit language, the necessity determination and application of an alternate benefit will be made according to that contract. Providers should submit complete documentation to support medical necessity if an exception is claimed.

Procedure, Diagnosis, and Imaging Requirements

Implant surgical codesCDT/D

D6010	Surgical placement of implant body; endosteal implant.
D6011	Surgical access to an implant body (second stage implant surgery).
D6013	Surgical placement of mini implant.
D6055	Connecting bar implant or abutment supported.

Abutment and prosthesis codes (partial list)CDT/D

D6056	Prefabricated abutment - includes modification and placement.
D6057	Custom fabricated abutment - includes placement.
D6051	Interim abutment.
D6052	Semi-precision attachment abutment.
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.
D6114	Implant/abutment supported fixed denture for dentulous arch - maxillary.
D6115	Implant/abutment supported fixed denture for dentulous arch - mandibular.

1–10 of 16

1/2

Implant-supported crown and retainer codes (partial list)CDT/D

D6065	Implant supported porcelain/ceramic crown.
D6066	Implant supported crown - porcelain fused to high noble alloys.
D6082	Implant supported crown - porcelain fused to predominantly base alloys.
D6083	Implant supported crown - porcelain fused to noble alloys.
D6084	Implant supported crown - porcelain fused to titanium or titanium alloys.
D6086	Implant supported crown - predominantly base alloys.
D6087	Implant supported crown - noble alloys.
D6088	Implant supported crown - titanium and titanium alloys.
D6068	Abutment supported retainer for porcelain/ceramic FPD.
D6069	Abutment supported retainer for porcelain fused to metal FPD (high noble metal).

Repairs and pontic codes (partial list)CDT/D

D6090	Repair implant supported prosthesis, by report.
D6092	Re-cement or re-bond implant/abutment supported crown.
D6093	Re-cement or re-bond implant/abutment supported fixed partial denture.
D6096	Remove broken implant retaining screw.
D6205	Pontic - indirect resin based composite.
D6210	Pontic - cast high noble metal.
D6240	Pontic - porcelain fused to high noble metal.
D6250	Pontic - resin with high noble metal.

Diagnosis referenceICD-10

ICD-10-CM

Diagnoses for dental diseases and conditions: see current CDT code book for details.

Required imaging recency — Documentation must include recent diagnostic radiographs

Required imaging timeframeDiagnostic radiographic images within the preceding 12 months are required for documentation of necessity.

When radiographs insufficientIf necessity is not clear on radiographs, include intra-oral photographs, patient treatment notes, and a narrative explaining extraordinary circumstances.

Plan-specific alternate benefitsPlans without a missing-tooth clause may apply alternate benefits; imaging requirement still applies when determining necessity or alternate benefit application.

Preauthorization, Documentation, and Provider Responsibilities

Prior Authorization

Preauthorization and plan-dependent benefit determination

Prior to implant placement and restoration a complete exam, treatment plan and appropriate imaging must be completed. Some plans contain alternate benefit or missing-tooth provisions that may restrict coverage; verify plan contract terms before proceeding. When less costly dental services can adequately restore occlusion, an alternate (least-cost) benefit may be applied and replacement with multiple implant-supported restorations in the same arch may be denied as not medically necessary unless the group contract specifies otherwise.

Complete dental exam, medical/dental history, full-mouth imaging, and treatment plan required prior to implant placement
Check group contract for missing-tooth clause or alternate benefit provisions
Alternate (least-cost) benefit may be applied when less costly services adequately restore function

Billing Rule

Alternate benefit / least-cost alternative

When less costly dental services can adequately restore occlusion, replacement with multiple implant-supported restorations in the same arch may be deemed not medically necessary and an alternate benefit may be applied per group contract. Determinations about least-cost alternatives are plan-dependent; confirm whether the member's plan allows alternate benefits to replace all missing teeth or limits implant coverage.

Alternate benefit / least-cost alternative may be applied per group contract
Replacement of multiple teeth in same arch by implant-supported restorations may be denied if less costly adequate alternatives exist

Documentation Required

Required documentation for coverage

Documentation must include diagnostic radiographic images within the preceding 12 months. If radiographs do not clearly demonstrate medical necessity, include intra-oral photographs, patient treatment notes, and a narrative explaining extraordinary circumstances. Repair or replacement of implant prosthetics (e.g., fractured porcelain, loose abutment or screw) requires a detailed narrative; benefits are contract dependent.

Diagnostic radiographs within the preceding 12 months required
If necessity is not obvious on radiographs, include intra-oral photos, treatment notes, and narrative
Detailed narrative required for repair/replacement of implant prosthetics; coverage is contract dependent

Documentation Required

Pre-procedure evaluation and special documentation

Prior to implant placement and restoration a thorough dental exam, medical/dental history, full mouth imaging, and treatment plan must be completed. For injuries from external trauma, refer the claim to the subscriber's medical plan first, as many medical plans cover tooth replacement related to accidental injury. A temporary/provisional implant-supported prosthesis is considered inclusive with the final restoration. Implant placement/restoration is not a covered benefit for third molar sites.

Thorough dental exam, medical/dental history, full-mouth imaging, and treatment plan required before placement
Refer traumatic-extraction cases to medical plan first when applicable
Temporary/provisional prosthesis considered inclusive with final restoration
Implant placement/restoration not covered for third molar sites

Documentation Required

Allergy documentation

Replacement due to metal allergy or sensitivity will be considered only with submission of physician documentation and the associated allergy report.

Submit physician documentation and allergy report to support coverage for replacement due to metal allergy/sensitivity

Denial Risk

Provider return / cementation and third molar replacement note

If a subscriber does not return for cementation the service is incomplete and no benefit is payable. The delivery date for implant-supported prosthetics is considered the date of initial delivery depending on provider contract; the type of cement (permanent vs temporary) does not determine the delivery date.

No benefit payable if member fails to return for cementation — service considered incomplete
Delivery date is date of initial delivery per provider contract
Type of cement is not determinative of delivery date

Background and Scope

Implant-supported crowns and fixed partial dentures are intended to replace missing teeth resulting from accidental traumatic injury, pathologic disorders necessitating extraction, congenitally missing teeth, or congenital disorders of teeth that require extraction. Services must align with generally accepted standards of dental practice and be clinically necessary rather than cosmetic or for convenience.

The policy notes that tooth–implant combination fixed partial dentures have demonstrated lower survival in meta-analyses and are approached cautiously; inability to wear removable appliances or failed corrective procedures may justify implant placement when documented. Prosthetic restoration and implant coverage remain subject to plan contract provisions and alternate benefit rules.

Standards and Definitions

Generally accepted standards of dental practice

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

ApplicationServices must be in accordance with these standards in terms of type, frequency and extent, be effective for the patient’s condition, not primarily for convenience, not cosmetic, and not more costly than an appropriate alternative.

Sources consideredIncludes peer-reviewed dental evidence, specialty society recommendations/criteria, recognized practicing dentists, and other relevant credible sources.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyImplant Fixed Prosthetics - Crowns and Fixed Bridges

Policy CodePolicy 06-001

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review Date

Key ActionObtain a complete exam, treatment plan, and diagnostic imaging prior to implant placement and restoration.

SourceLink

On This Page