CurrentBlue Cross Blue Shield - WisconsinPolicy 06-701

Abutment Crowns Fixed Partial Dentures (2024 Policy) PDF. Opens in a new window

Policy governs clinical criteria, documentation, and coding guidance for coverage determination of retainer crowns and fixed partial dentures (bridges, pontics, retainer crowns) under Blue Cross Blue Shield - Wisconsin dental plans; contract-specific clauses (missing tooth clause, age limits, alternate benefits) may modify coverage.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyAbutment Crowns Fixed Partial Dentures (2024 Policy) PDF. Opens in a new window

Policy CodePolicy 06-701

Change TypeRevised / Annual review

Effective DateJan 1, 2024

Next Review Date

Key ActionSubmit current (within 12 months) dated diagnostic pretreatment radiographs including the radiographic apex; if radiographs are not definitive include intraoral photos and clinical chart notes with rationale.

SourceLink

POLICY UPDATE CHANGES

Policy header shows revised/publish date 01/01/2024 and last review date 10/25/2023; multiple prior annual reviews listed through 11/01/2023.

30+Number of specific CDT codes listed

ManyClinical inclusion/exclusion criteria

Contract dependentContract-dependent rules (MTC/age/alternate benefits)

Coverage Summary

This policy governs clinical criteria, documentation, and coding guidance for coverage determination of retainer crowns and fixed partial dentures (bridges, pontics, retainer crowns) under Blue Cross Blue Shield - Wisconsin dental plans. Contract-specific provisions such as the Missing Tooth Clause (MTC), age limits, and alternate benefits (for example removable partial dentures) may modify coverage for services otherwise meeting clinical criteria.

Policy metadata

Policy number06-701

Effective date01/01/2024

Last review10/25/2023

StatusCURRENT

SubjectRetainer Crowns and Fixed Partial Dentures (bridges)

Scope summaryPolicy governs clinical criteria, documentation, and coding guidance for coverage determination of retainer crowns and fixed partial dentures; contract-specific clauses (missing tooth clause, age limits, alternate benefits) may modify coverage.

Medical / Dental Necessity Criteria

Specific Exclusions / Not Covered Conditions

Not covered or will not be considered when ANY of the following apply:

ANY of the following

Retainer crowns/FPDs placed for repair of complications from wear, attrition, abrasion, erosion or abfraction
FPDs placed for occlusal alterations and/or changes in vertical dimension or for treatment of TMD/craniomandibular disorders
Replacement of existing FPDs unless supported by recurrent caries, fracture, or defective restoration
FPDs placed for correction of developmental or congenital defects (congenitally missing teeth, unerupted teeth, spacing due to migration/drifting) unless group contract indicates coverage
Pontics when insufficient space exists
FPDs supported by inlay retainer restorations
Tooth-implant supported FPDs (combination tooth-implant prostheses) are not considered for benefits
Splinting of teeth by retainer crowns is not routinely covered unless group contract indicates coverage
Pontics fabricated for closing spaces where there is no missing natural tooth
Benefits not considered for closure of contacts unless caused by caries, tooth fracture, or defective restoration
Benefits not considered when one or more retainers exhibits subgingival/sub-osseous caries that compromise the supracrestal tissue attachment without addressing periodontal considerations
Existing FPDs that are discolored, misshapen or have compromised cosmetics do not qualify
Benefits not considered when one or more retainers exhibits caries into the furcation

Missing Tooth Clause and Plan-Dependent Rules

Coverage depends on member's contract; apply the following logic:

ALL of the following

ALL of the following
- Replacement of teeth missing prior to member's plan effective date has no benefit (MTC)
- Pontic portion of FPD will deny due to MTC; retainers reviewed on their own merit
ALL of the following
- If fewer than three missing teeth in an arch, determination made as to appropriateness of FPD as a whole
- If three or more missing teeth in an arch, an alternate benefit of a removable partial denture may be contract dependent; retainers reviewed on their own merit

Additional Considerations / Limits

ALL of the following

Number of pontics necessary shall not exceed the normal complement of teeth
Cantilever FPDs: anterior cantilevers with cuspids as retainers replacing lateral incisors may be benefited; posterior cantilevers allow only one cantilever pontic with two retainers supporting a single pontic
Crown-to-root ratios poorer than 1:1 create less than ideal situations and require assessment of full mouth dental condition, medical/dental/periodontal history, maintenance, age, and occlusion
Age limitation is group contract dependent
Replacement due to metal allergy/sensitivity considered only with physician documentation and associated allergy report

Provider Actions & Documentation Requirements

Documentation Required

Radiographs and diagnostic documentation required

Submit current (within 12 months), dated diagnostic pretreatment radiographic images that include the radiographic apex. If radiographs are not definitive, include intraoral photographs and clinical chart notes stating the rationale for indirect restoration coverage.

Documentation Required

Periodontal and endodontic documentation may be requested

Provide current dated 6‑point periodontal charting, clinical chart notes, intra‑oral photographs, and history of periodontal therapy when requested. If periodontal disease is present, submit evidence of definitive periodontal therapy and ongoing maintenance. For endodontic concerns, provide endodontic records demonstrating appropriate obturation or planned endodontic therapy as applicable.

Prior Authorization

Benefits subject to contract-specific provisions

Verify member contract terms before approval. Determine if a Missing Tooth Clause (MTC), age limits, or alternate benefits (for example, removable partial denture) apply, and confirm how pontic and retainer coverage will be adjudicated under the group contract.

Denial Risk

Incomplete treatment - no benefit if delivery not completed

If a patient does not return for delivery, the service is incomplete and no benefit is available.

Billing Rule

Temporary restorations considered part of final restoration

Temporary or provisional retainer crowns and fixed partial dentures are considered component parts of the final restoration and not billed separately.

Background

This policy defines the appropriate use of retainer crowns and fixed partial dentures to restore function by replacing missing teeth and requires that coverage determinations be made against generally accepted standards of dental practice and contract-specific provisions (for example, the Missing Tooth Clause (MTC)), with retainers and pontics reviewed according to those standards and the member's contract.

Definitions:

• Missing Tooth Clause (MTC): A contract provision denying benefits for replacement of teeth missing prior to the member's plan effective date; does not apply to replacement prosthetics.

• Delivery date: Considered the date of initial cementation or bonding regardless of cement type; the date of service may be contract dependent.

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

OpenPayer

Abutment Crowns Fixed Partial Dentures (2024 Policy) PDF. Opens in a new window

Coverage Summary

Medical / Dental Necessity Criteria

Coding (CDT Examples)

Provider Actions & Documentation Requirements

Background

Revision History