Blue Cross Blue Shield Nevada implant crowns Coverage

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.

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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

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

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

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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.

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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).

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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.

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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.

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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

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.
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.

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Crowns and retainers (abutment & implant supported)mixedCovered

D6094	Abutment supported crown titanium and titanium alloys.
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.

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Repairs, recementation, pontics and related prosthetic codesmixed

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.
D6211	Pontic - cast predominantly base metal.
D6212	Pontic - cast noble metal.
D6214	Pontic - titanium and titanium alloys.
D6240	Pontic - porcelain fused to high noble metal.

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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).

OpenPayer

Implant Fixed Prosthetics - Crowns and Fixed Bridges

Coverage and Medical Necessity Criteria

Procedure and Billing Codes

Provider Requirements and Utilization Management

Background and Scope

Definitions and References