Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield Nevada implant crowns Cover…
    Ask Trek AI about this page
    CurrentBlue Cross Blue Shield - NevadaPolicy 06-001

    Implant Fixed Prosthetics - Crowns and Fixed Bridges

    Customize your policy alerts

    Sign up for Blue Cross Blue Shield - Nevada Policy 06-001 alerts

    Get alerted when Policy 06-001 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Policy governing review and coverage determinations for implant-supported crowns, abutment-supported crowns, and implant/abutment supported fixed partial dentures for replacement of missing teeth for Blue Cross Blue Shield - Nevada members.

    Policy Summary
    PayerBlue Cross Blue Shield - Nevada
    PolicyImplant Fixed Prosthetics - Crowns and Fixed Bridges
    Policy CodePolicy 06-001
    Change TypeNo material change
    Effective DateJan 1, 2021
    Last ReviewDec 5, 2020
    Next Review Date
    Key ActionPrior to implant placement and restoration, complete a thorough dental exam, full mouth imaging and a treatment plan with diagnostic radiographs dated within the preceding 12 months.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    20+procedure codes enumerated in coding section

    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.

    12 months
    documentation timeframe for necessity
    Not coveredthird molar exclusion
    Inclusiveprovisional restorations
    25+literature references listed
    Multiplerevision history present

    Coverage and Medical Necessity Criteria

    inv-01: Clinical indications for implant prosthetics

    Covered when ANY of the following tooth‑loss reasons apply and documentation supports generally accepted standards of dental care:

    Acceptable indications: Accidental traumatic injuries to sound, natural teeth from an external blow resulting in extraction; a pathologic disorder resulting in extraction; congenitally missing teeth; congenital disorders of teeth resulting in extraction.

    Clinical Indications: [[chunk 2]]

    inv-02: Administrative and documentation criteria

    Covered when ALL of the following administrative and documentation criteria are met (plan/group contract dependent where noted):

    Pre-treatment requirements: Thorough dental examination, medical and dental history, full mouth imaging, and completed treatment plan prior to implant placement and restoration.

    Chunk 5.

    Radiographs and supporting documentation: Diagnostic radiographic images within the preceding 12 months. If radiographs do not clearly demonstrate necessity, provide intra‑oral photographs, patient treatment notes and narrative explaining extraordinary circumstances.within the preceding 12 months

    Chunk 7.

    Documentation for metal allergy: Replacement for documented metal allergy/sensitivity requires submission of physician documentation and associated allergy report.

    Chunk 5.

    Temporary/provisional restorations: Temporary or provisional implant‑supported restorations are considered inclusive with the final restoration (no separate benefit).

    Chunk 7.

    Plan/contract dependent benefit limits: If the member's plan contains a missing tooth clause there is no benefit for replacement of missing teeth with implant‑supported prostheses; if the plan does not contain a missing tooth clause, alternate benefit determinations may apply per group contract.

    Chunk 7.

    inv-03: Not medically necessary / exclusions (plan-dependent)

    Not medically necessary or excluded in certain situations:

    Replacement of multiple teeth when less costly alternatives suffice: Replacement of multiple teeth in the same arch with implant‑supported crowns or fixed partial dentures is not medically necessary when less costly dental services can adequately restore occlusion (unless specified by group contract).

    Chunks 4 and 7.

    Tooth‑implant supported fixed partial dentures may be excluded or not considered for benefits because studies/meta‑analysis report lower survival rates compared with solely implant‑supported or solely tooth‑supported fixed partial dentures; this is plan specific.

    Chunk 7.

    Implants for non‑missing teeth / third molars: Implant placement/restoration is not appropriate where teeth are not missing, including replacement of third molars; implant placement/restoration for third molar sites is not a covered benefit.

    Chunks 4 and 7.

    Replacement of multiple teeth in the same arch with implant-supported crowns or implant/abutment-supported fixed partial dentures is not medically necessary when less costly dental services can adequately restore occlusion and function, unless the group contract specifically provides otherwise. This exclusion also notes that prosthetic restoration of implants may be subject to contract limitations or alternate benefit provisions and that services left incomplete (for example, when a subscriber does not return for cementation) are not payable.

    Federal and state law, the member's contract language, and applicable Dental Policy take precedence over these Clinical UM Guidelines. Plans and lines of business may choose whether to implement the guideline for utilization review; contact the customer service number on the member's card to determine whether pre-service review is required for a specific plan.

    Specific exclusions include implant placement or restoration at third molar sites, which is stated as not a covered benefit. In addition, implants are not appropriate where teeth are not missing; placement/restoration for non-missing teeth (including third molars) is excluded. Where other less costly dental services can adequately restore occlusion, replacement of multiple teeth with implant-supported prostheses is considered not medically necessary. Prosthetic and benefit limitations may also be determined by group contract or alternate benefit provisions.

    Procedure and Billing Codes

    General implant procedure and accessory codesmixed
    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 abutment.
    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 24
    1/3
    Crowns and retainers (abutment & implant supported)mixedCovered
    D6094Abutment supported crown titanium and titanium alloys.
    D6065Implant supported porcelain/ceramic crown.
    D6066Implant supported crown - porcelain fused to high noble alloys.
    D6082Implant supported crown - porcelain fused to predominantly base alloys.
    D6083Implant supported crown - porcelain fused to noble alloys.
    D6084Implant supported crown - porcelain fused to titanium or titanium alloys.
    D6086Implant supported crown - predominantly base alloys.
    D6087Implant supported crown - noble alloys.
    D6088Implant supported crown - titanium and titanium alloys.
    D6068Abutment supported retainer for porcelain/ceramic FPD.
    1–10 of 14
    1/2
    Repairs, recementation, pontics and related prosthetic codesmixed
    D6090Repair implant supported prosthesis, by report.
    D6092Re-cement or re-bond implant/abutment supported crown.
    D6093Re-cement or re-bond implant/abutment supported fixed partial denture.
    D6096Remove broken implant retaining screw.
    D6205Pontic - indirect resin based composite.
    D6210Pontic - cast high noble metal.
    D6211Pontic - cast predominantly base metal.
    D6212Pontic - cast noble metal.
    D6214Pontic - titanium and titanium alloys.
    D6240Pontic - porcelain fused to high noble metal.
    1–10 of 17
    1/2
    Radiograph recency
    Required diagnostic radiographsDiagnostic radiographic images within the preceding 12 months are required to document necessity for implant-supported crowns, abutment-supported crowns, or implant/abutment supported fixed partial dentures.

    Provider Requirements and Utilization Management

    Prior Authorization

    Prior authorization depends on plan

    Prior authorization or pre-service review may be required for implant placement and prosthetic restoration depending on the member's plan/line of business and provider contract. Contact the customer's service number on the member's ID card to determine whether a review or prior authorization is required prior to performing services.

    • Pre-service review requirements vary by plan/line of business
    • Some plans use alternate processes or contract-specific provisions
    Documentation Required

    Documentation required prior to placement

    Before implant placement and restoration, providers must complete and retain required documentation: a thorough dental exam, medical and dental history, full‑mouth imaging (diagnostic radiographs within the preceding 12 months) and a treatment plan. When radiographs do not clearly document necessity, include intra-oral photographs, treatment notes and a narrative describing extraordinary circumstances. Failure to provide required documentation may trigger utilization review or denial.

    Background and Scope

    Implant-supported crowns and implant/abutment-supported fixed partial dentures are prosthetic options used to replace missing teeth resulting from trauma, pathologic disorders, congenital absence, or extractions related to congenital dental disorders. Treatment decisions should follow generally accepted standards of dental practice, weigh effectiveness and necessity against alternatives, and consider contract or alternate benefit limitations. Temporary or provisional implant-supported restorations are considered inclusive with the final restoration.

    Definitions and References

    Generally accepted standards of dental practice — definition
    DefinitionGenerally accepted standards of dental practice: standards based on credible peer‑reviewed dental literature, specialty society recommendations, views of recognized dentists in the clinical area, and other relevant credible sources.
    Clinical 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, and not cosmetic.
    Cost considerationBenefits may be limited to treatments that meet standards of care at the lowest cost that properly address the patient’s condition per plan contract.
    References — selected dental implant literature
    Leblebicioglu et al., JADA 2007A review of the functional and esthetic requirements for dental implants (J Amer Dent Assoc 2007;138:321-329).
    Policy Summary
    PayerBlue Cross Blue Shield - Nevada
    PolicyImplant Fixed Prosthetics - Crowns and Fixed Bridges
    Policy CodePolicy 06-001
    Change TypeNo material change
    Effective DateJan 1, 2021
    Last ReviewDec 5, 2020
    Next Review Date
    Key ActionPrior to implant placement and restoration, complete a thorough dental exam, full mouth imaging and a treatment plan with diagnostic radiographs dated within the preceding 12 months.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaProcedure and Billing CodesProvider Requirements and Utilization ManagementBackground and ScopeDefinitions and References
    • Dental examination, medical/dental history, full mouth imaging, and treatment plan required prior to implant placement/restoration
    • Diagnostic radiographic images must be within the preceding 12 months
    • If necessity is not obvious on radiographs, include intra‑oral photos, patient treatment notes, and narrative justification
    • If replacement is due to metal allergy/sensitivity, submit physician documentation and allergy report
    Denial Risk

    Potential triggers for utilization review/denial

    When requesting review or submitting claims, providers should be aware that services may be denied if they do not meet generally accepted standards of dental care, are not a covered benefit under the group contract (for example, missing‑tooth clauses or contract limits), or when less costly, appropriate alternatives exist. Providers may be subject to utilization review based on plan selection or billing patterns.

    • Services not meeting standards of dental care or not a covered benefit may be denied
    • Replacement for missing teeth may be excluded by missing‑tooth clauses or alternate benefit provisions
    • Less costly restorative options should be considered before implant‑supported prostheses when appropriate
    • Providers may be identified for review based on frequency or atypical billing patterns
    Note

    Consider less costly alternatives first

    Providers should consider and document less costly, clinically appropriate alternatives before planning implant‑supported crowns or fixed partial dentures. Ensure the treatment plan explains why alternate therapies would be inadequate.

    • Document consideration of less costly services and rationale for choosing implant‑supported restoration
    • Implant placement/restoration is not a covered benefit for third molar sites
    Documentation Required

    Documentation and contacts for utilization review

    If you are unsure whether a prior review is required or how to submit documentation for utilization review, contact the plan's customer service number on the member's card. Processes and requirements may differ by commercial, FEP, or other lines of business; plans may also use guidelines for provider education or targeted provider review.

    • Contact customer service to determine if review/authorization is required
    • Plan-specific processes and contract language take precedence over Clinical UM Guidelines
    • Clinical guidelines may be used for targeted provider review or education when plans opt not to adopt them universally
    Esquivel-Upshaw, Phillips science of dental materials
    Dental implants. In: Anusavice KJ, ed. Phillips science of dental materials. 11th ed. Saunders;2003:759-780.
    Weber & Zimering, Evidence-Based Dent Pract 2012Survival and complication rates of fixed partial dentures supported by a combination of teeth and implants (2012 Sep;12(3 Suppl):215-6).
    Meta-analyses and long-term studiesMultiple clinical studies and meta-analyses cited on implant survival, healing, immediate placement and impact of smoking (see references 14-25 for details).