CurrentBlue Cross Blue Shield - WisconsinPolicy 06-701

Abutment Crowns Fixed Partial Dentures (2022 Policy) PDF. Opens in a new window

Clinical utilization guideline describing dental review criteria, documentation requirements, coding examples and coverage limitations for retainer crowns and fixed partial dentures (pontics/bridges). Applies where plan coverage is contract-dependent and may be superseded by group contract terms (e.g., missing tooth clause).

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyAbutment Crowns Fixed Partial Dentures (2022 Policy) PDF. Opens in a new window

Policy CodePolicy 06-701

Change TypeRevised (last review 10/06/2021)

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionInclude recent, dated pretreatment radiographs (with apex) and any required intra-oral photos, clinical notes, and current 6-point periodontal charting when submitting FPD/retainer crown coverage requests.

SourceLink

POLICY UPDATE CHANGES

Document status indicated as Revised with last review 10/06/2021; prior revisions and annual reviews noted.

>30CDT codes listed (informational)

ManyCriteria items (inclusion/exclusion rules)

Contract-dependentMissing Tooth Clause effect

Coverage Summary

This guideline covers review criteria for Retainer Crowns and Fixed Partial Dentures (bridges/pontics) to determine dental necessity and benefit applicability. Coverage is contract-dependent and plan contract language (including the Missing Tooth Clause (MTC)) may supersede these criteria and result in pontic denials when teeth were missing prior to the member's plan effective date. Effective date: 01/01/2022. Last review: 10/06/2021.

Key Policy Facts

Policy Number06-701

Effective Date2022-01-01

Last Review2021-10-06

Coverage Stancemixed

ScopeClinical utilization guideline for retainer crowns and fixed partial dentures; contract language (e.g., Missing Tooth Clause) and federal/state law take precedence

General Coverage Criteria

General Coverage Criteria (benefit considered when ALL conditions met as applicable)

Covered when ALL of the following apply to the retainer tooth(s) and prosthesis as specified:

ALL of the following

Retainer teeth supporting a fixed partial denture must exhibit periodontal and endodontic health and be aligned to direct forces of occlusion along the long axis of the teeth.
Appropriate clinical indications (ANY of)
- Accidental traumatic injuries to sound, natural teeth from an external blow resulting in extraction
- Pathologic disorder resulting in extraction
- Congenitally missing teeth
- Congenital disorders of teeth resulting in extraction
Retainer tooth minimum structural criteria
- Anterior retainer: significant loss of coronal tooth structure due to caries, fracture, or defective restoration and/or involvement of one or both incisal angles.
- Posterior retainer: significant missing tooth structure due to caries, fracture, or defective restoration; large restorations that compromise function or loss of support for the cusps where the cusps are undermined (one or more cusps) with compromised mesial or distal marginal ridges.
Periodontal health: teeth with uncontrolled/untreated periodontal disease (radiographic or charting evidence, loss of supporting bone including furcation) are not considered unless definitive periodontal therapy and maintenance have been performed. Current dated 6‑point periodontal charting and history may be requested.
Endodontic status: placement on a tooth with untreated/unresolved periapical or periradicular pathology or unresolved carious lesion near the pulp without planned endodontic therapy will not be considered.
Endodontic obturation quality: root canal filling should be as close as possible to apical constriction (ideal 0.5-1.2 mm); avoid gross overextension (>2 mm) or underfill (>2 mm short with patent canals).
Temporary/provisional retainer crown/FPD is considered a component part of the final restoration.
Primary tooth in adult dentition: must demonstrate intact root structure, adequate periodontal support, no active periodontal disease, occlusal function with opposing tooth, and radiograph must show no permanent successor or successor unlikely to erupt.

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Special / Conditional rules

Additional conditional rules and plan-dependent determinations:

ALL of the following

If one retainer for an FPD is denied, the entire fixed partial denture may be denied.
For plans WITHOUT a missing tooth clause: if less than three teeth are missing in the arch, determination is made on appropriateness of FPD as a whole; if three or more teeth missing, an alternate benefit of a removable partial denture may be contract dependent; retainers reviewed on their own merit.
Cantilever FPDs: anterior cantilever with cuspids as retainer replacing lateral incisors may be benefited; posterior cantilever: only one cantilever pontic may be allowed and two retainers required to support single pontic; both posterior retainers must meet requirements for a stand-alone crown to eliminate splinting restriction.
Replacement due to metal allergy/sensitivity will be considered only upon submission of physician documentation with associated allergy report.

Provider Actions & Documentation Requirements

Documentation Required

Pre-treatment radiographs and diagnostic documentation required

Must include recent, dated, properly identified pretreatment diagnostic radiographic images that include the radiographic apex. Intra-oral photographs, clinical chart notes, current dated 6-point periodontal charting, and history of periodontal therapy may also be required when applicable.

Radiographs that include the radiographic apex
Intra-oral photographs
6-point periodontal charting (current, dated)
History of periodontal therapy
Clinical chart notes

Documentation Required

Adjunctive documentation when radiograph inconclusive

When the radiograph does not clearly demonstrate the need for a fixed partial denture, provide additional diagnostic information to support the indication for an indirect restoration.

Intraoral photographs of the affected tooth/teeth
Clinical chart notes stating the rationale for indirect restoration coverage

Denial Risk

Missing Tooth Clause (MTC) applications

For plans that include a Missing Tooth Clause (MTC), replacement of teeth missing prior to the member's plan effective date will result in denial of the pontic portion; retainer teeth will be reviewed on their own merit. Confirm the member's contract to determine whether the MTC applies.

Pontic portion denied if tooth was missing prior to the plan effective date
Retainer teeth reviewed on their own merit
Confirm member contract for MTC applicability

Denial Risk

Periodontal and endodontic exclusions risk

Claims may be denied when periodontal disease is uncontrolled/untreated or when endodontic pathology is unresolved or obturation is inadequate. Review clinical and radiographic evidence of periodontal and endodontic status prior to approving indirect restorations.

Uncontrolled or untreated periodontal disease (radiographic or charting evidence, loss of supporting bone, furcation involvement)
Unresolved periapical or periradicular endodontic pathology
Inadequate root canal obturation: gross overextension (>2 mm) or underfill (>2 mm short with patent canals)

Documentation Required

Metal allergy replacement documentation

Replacement of an indirect restoration for metal allergy or sensitivity will be considered only with supporting medical documentation.

Physician documentation and associated allergy report required for consideration

Relevant Procedure Codes (CDT)

CDT codes (applicable procedures - informational only)mixed

D6210	Pontic - cast high noble metal
D6211	Pontic - cast predominantly base metal
D6212	Pontic - cast noble metal
D6214	Pontic - titanium
D6240	Pontic - porcelain fused to high noble metal
D6241	Pontic - porcelain fused to predominantly base metal
D6242	Pontic - porcelain fused to noble metal
D6243	Pontic - porcelain fused to titanium and titanium alloys
D6245	Pontic - porcelain/ceramic
D6250	Pontic - resin with high noble metal

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CDT procedure codes listed in this document are provided as informational examples only; actual coverage for any code depends on the member's contract terms and the clinical and diagnostic documentation submitted. For plans that include a Missing Tooth Clause, the pontic portion of a bridge will be denied when the tooth was missing prior to the member's plan effective date; retainer teeth will be reviewed separately on their own merit.

Background and Definitions

Background: These guidelines define clinical standards and utilization review criteria for fixed partial dentures and retainer crowns to determine dental necessity and benefit applicability. Reviews are based on generally accepted standards of dental practice and require supporting diagnostic documentation (e.g., recent pretreatment radiographs including the apex, intra-oral photos, clinical notes, and current 6-point periodontal charting) when applicable. Federal and state law, as well as the member's contract language and Dental Policy, take precedence over these Clinical UM Guidelines. The scope of this document applies where plan coverage is contract-dependent and individual plans may choose whether to implement the guideline for utilization review.

Definitions

Policy Scope

Revision History

10/06/2021non-material_revisionLatest

Document status Revised with last review 10/06/2021; listed as Annual Review (no specific clinical policy statement changes).

12/05/2020non-material_revision

Revision noted 12/05/2020 as Annual Review (no specific clinical policy statement changes indicated).

09/09/2020non-material_revision

Revision noted 09/09/2020 as Annual Review (no specific clinical policy statement changes indicated).

04/22/2019non-material_revision

Revision dated 04/22/19 for criteria numbering (non‑material to clinical policy content per history).

03/04/2019non-material_revision

Revision dated 03/04/19 recorded as external facing policy update (no specific clinical policy statement changes called out).