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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield WI implant crowns coverage …
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    CurrentBlue Cross Blue Shield - WisconsinPolicy 06-001

    Implant/Abutment Supported Fixed Prosthetics - Crowns and Fixed Partial Dentures

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    Defines medical necessity, documentation, coding guidance, and coverage criteria for implant- and abutment-supported crowns and fixed partial dentures for Blue Cross Blue Shield - Wisconsin members.

    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyImplant/Abutment Supported Fixed Prosthetics - Crowns and Fixed Partial Dentures
    Policy CodePolicy 06-001
    Change TypeNo material change
    Effective DateJan 1, 2025
    Last ReviewOct 29, 2024
    Next Review Date
    Key ActionObtain current (within 12 months), dated diagnostic preoperative radiographs and complete a thorough dental evaluation and treatment plan prior to implant placement.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsradiograph recency

    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.

    one
    max cantilever
    excludedthird molar coverage
    inclusivetemporary restoration

    Coverage Criteria — Medical Necessity and Exclusions

    Medical necessity criteria for implant/abutment supported crowns and FPDs

    Covered when ALL of the following are met:

    Pre-procedure requirements: Prior to implant placement and restoration, a thorough dental evaluation, medical and dental history, full mouth imaging, and treatment plan must be completed.
    Appropriate clinical indications (at least one): Missing tooth/teeth due to accidental traumatic injury with extraction/avulsion OR pathologic disorder resulting in extraction OR congenitally missing teeth OR congenital disorders of teeth resulting in extraction.
    Imaging/documentation: Current (within 12 months), dated, diagnostic, preoperative radiographic images; if necessity not obvious on radiographs, provide intra-oral photographs, treatment notes and a narrative explaining extraordinary circumstances.radiographs within 12 months

    Not medically necessary / Exclusions

    Non-covered / Not medically necessary situations: Replacement when teeth are not missing (including third molars); replacement of multiple teeth in same arch when less costly professionally acceptable alternatives can restore occlusion; implant placement for third molar sites not covered (contract dependent).
    Aesthetic or minor functional reasons: Replacement of implant/abutment supported prosthetics will not be considered for closure of contacts unless prosthetics are defective, or for aesthetic reasons.
    Tooth-implant supported FPDs: Tooth-implant supported fixed partial dentures may not be considered for benefits due to lower survival rates compared to solely implant- or tooth-supported FPDs.

    Implant/abutment supported restorations are considered appropriate only when tooth/teeth are missing and one of the listed clinical indications is present. Appropriate indications include accidental traumatic injury with extraction/avulsion, a pathologic disorder resulting in extraction, congenitally missing teeth, or congenital disorders of teeth resulting in extraction. Services using implant-supported crowns or fixed partial dentures are not appropriate where teeth are not missing, including replacement of third molars, and implant restorations may be subject to contract limitations or alternate benefit provisions.

    Replacement, repair, or re-provisioning of implant/abutment supported prosthetics will not be considered for aesthetic reasons or solely to close contacts unless the prosthetic is documented as defective. Documentation supporting defect or functional loss is required to consider coverage for contact closure or cosmetic concerns.

    Replacement of multiple teeth in the same arch with implant-supported crowns or fixed partial dentures is not medically necessary when less costly professionally acceptable dental services exist that can adequately restore occlusion and function. When such alternatives can restore function, an alternate benefit or step-therapy provision may be applied according to the member's group contract.

    Coding — CDT and Diagnosis Codes

    Included CDT codes - group 1CDT
    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 implant abutment placement
    Included CDT codes - group 2CDT
    D6052Semi-precision attachment abutment
    D6110Implant/abutment supported removable denture for edentulous arch - maxillary
    D6111Implant/abutment supported removable denture for edentulous arch - mandibular
    D6112Implant/abutment supported removable denture for partially edentulous arch - maxillary
    D6113Implant/abutment supported removable denture for partially edentulous arch - mandibular
    D6114Implant/abutment supported fixed denture for dentulous arch - maxillary
    D6115Implant/abutment supported fixed denture for dentulous arch - mandibular
    D6116Implant/abutment supported fixed denture for partially dentulous arch - maxillary
    D6117Implant/abutment supported fixed denture for partially dentulous arch - mandibular
    D6058Abutment supported porcelain/ceramic crown
    1–10 of 17
    1/2
    Included CDT codes - group 3CDT
    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
    D6067Implant supported crown - high noble alloys
    D6086Implant supported crown - predominantly base alloys
    D6087Implant supported crown - noble alloys
    D6088Implant supported crown - titanium and titanium alloys
    1–10 of 18
    1/2
    Included CDT codes - group 4CDT
    D6194Abutment supported retainer for cast metal FPD - titanium and titanium alloys
    D6075Implant supported retainer for ceramic FPD
    D6076Implant supported retainer for FPD - porcelain fused to high noble alloys
    D6098Implant supported retainer - porcelain fused to predominantly base alloys
    D6099Implant supported retainer for FPD - porcelain fused to noble alloys
    D6120Implant supported retainer - porcelain fused to titanium and titanium alloys
    D6077Implant supported retainer for metal FPD - high noble alloys
    D6121Implant supported retainer for metal FPD - predominantly base alloys
    D6122Implant supported retainer for metal FPD - noble alloys
    D6123Implant supported retainer for metal FPD - titanium and titanium alloys
    1–10 of 28
    1/3
    Diagnosis codes (reference)ICD-10
    ICD-10-CMDiagnoses for Dental Diseases and Conditions - see the current CDT code book for details
    Radiograph Recency Requirements
    Required recencyDiagnostic, preoperative radiographic images must be current within 12 months (dated).
    Supplemental documentation when radiographs are inconclusiveIf necessity is not obvious on radiographs, include intra-oral photographs, patient treatment notes and a narrative explaining extraordinary circumstances.
    PurposeRadiographs and accompanying documentation are required to demonstrate medical necessity for implant/abutment supported crowns and fixed partial dentures.

    Provider Actions — Authorization, Documentation, and Operational Guidance

    Prior Authorization

    Prior Authorization May Be Required

    Prior authorization may be required for implant/prosthetic CDT codes. Check the member's group contract for prior authorization requirements and obtain approval when indicated before scheduling implant placement or prosthetic delivery.

    • Affected codes include, but are not limited to: D6010, D6011, D6013, D6055–D6068, D6070–D6099, D6110–D6123, D6194–D6195, D6205–D6250 (contract dependent).
    • Obtain prior authorization per contract when the plan requires it; failure to obtain prior authorization may result in denial or reduction of benefit.
    Documentation Required

    Pre-procedure Evaluation Required

    A thorough pre-procedure evaluation is required prior to implant placement and restoration. Complete documentation must be on file before implant surgery or prosthetic delivery.

    • A comprehensive dental evaluation, full medical and dental history, and documented treatment plan must be completed prior to implant placement.

    Background

    Dental implants are surgical components placed to replace missing tooth structure and to support crowns or fixed partial dentures. Typical indications for implant placement include tooth loss from trauma with extraction/avulsion, extraction due to a pathologic disorder, congenitally missing teeth, or congenital dental disorders leading to extraction. Prior to implant placement and restoration, a thorough dental evaluation, complete medical and dental history, full mouth imaging, and a treatment plan must be completed. Required documentation for medical necessity includes current (within 12 months), dated, diagnostic, preoperative radiographic images; if necessity is not evident on radiographs, include intra-oral photographs, treatment notes, and a narrative explaining extraordinary circumstances. Note that implant restorations and services for third molar sites or other situations may be limited by contract language or alternate benefit provisions.

    Definitions

    Implant/Abutment Supported Crowns and Fixed Partial Dentures — Definition
    DefinitionArtificial tooth or teeth attached to implant(s) and/or abutment(s) to replace one or more missing teeth.
    FunctionReplaces missing teeth and restores occlusion and function by being supported on implants/abutments.
    Clinical contextIndications include tooth loss from trauma, pathologic extraction, congenitally missing teeth, or congenital disorders resulting in extraction.
    Cantilever Implant/Abutment Supported Fixed Partial Denture — Definition & Limit
    DefinitionA fixed partial denture design in which one or more pontics extend beyond the retainer (cantilever design).
    Policy limitOnly one cantilever pontic may be an allowable benefit per cantilever implant/abutment supported fixed partial denture.
    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyImplant/Abutment Supported Fixed Prosthetics - Crowns and Fixed Partial Dentures
    Policy CodePolicy 06-001
    Change TypeNo material change
    Effective DateJan 1, 2025
    Last ReviewOct 29, 2024
    Next Review Date
    Key ActionObtain current (within 12 months), dated diagnostic preoperative radiographs and complete a thorough dental evaluation and treatment plan prior to implant placement.
    SourceLink
    On This Page
    Coverage Criteria — Medical Necessity and ExclusionsCoding — CDT and Diagnosis CodesProvider Actions — Authorization, Documentation, and Operational GuidanceBackgroundDefinitions
  1. Full-mouth imaging (or appropriate radiographs) and any additional diagnostic records needed to support medical necessity must be obtained and dated.
  2. For services related to accidental injury, refer first to the member's medical plan as many medical plans may be primary for traumatic dental loss.
    3. Documentation Required

    Allergy Documentation Required for Replacement

    Replacement due to documented metal allergy or sensitivity will be considered only with appropriate physician documentation and supporting allergy testing/report.

    • Submit a physician's letter explaining the diagnosis and medical necessity for replacement due to allergy.
    • Include the associated allergy report or test results with the request or claim to support coverage consideration.
    Billing Rule

    Temporary Restorations Inclusive with Final Restoration

    Temporary or provisional implant/abutment supported restorations are considered inclusive with the final restoration and are not reimbursed separately.

    • Temporary crowns, provisional abutments, or interim restorations related to implant-supported prosthetics are included in the final restoration benefit.
    • Do not bill separate CDT codes for temporary restorations when submitted with the final implant-supported prosthesis (contract dependent).
    Step Therapy

    Alternate Benefit / Step Therapy Guidance

    If a less costly, professionally acceptable alternative exists, an alternate benefit or step therapy may be applied in accordance with the group contract.

    • When plans include alternate benefit provisions, payment may be limited to a less costly service capable of restoring function (e.g., a removable partial denture instead of an implant-supported prosthesis).
    • Determinations about alternate benefits or step therapy are group contract dependent; document why an alternate benefit is not appropriate if requesting implant-level benefit.
    Clinical considerationPeri-implant health of the retainers must be considered when evaluating cantilever designs.