CurrentBlue Cross Blue Shield - WisconsinPolicy 06-001

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

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

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

onemax cantilever

excludedthird molar coverage

inclusivetemporary restoration

Coverage Criteria — Medical Necessity and Exclusions

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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.

Coding — CDT and Diagnosis Codes

Included CDT codes - group 1CDT

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 implant abutment placement

Included CDT codes - group 2CDT

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
D6112	Implant/abutment supported removable denture for partially edentulous arch - maxillary
D6113	Implant/abutment supported removable denture for partially edentulous arch - mandibular
D6114	Implant/abutment supported fixed denture for dentulous arch - maxillary
D6115	Implant/abutment supported fixed denture for dentulous arch - mandibular
D6116	Implant/abutment supported fixed denture for partially dentulous arch - maxillary
D6117	Implant/abutment supported fixed denture for partially dentulous arch - mandibular
D6058	Abutment supported porcelain/ceramic crown

1–10 of 17

1/2

Included CDT codes - group 3CDT

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
D6067	Implant supported crown - high noble alloys
D6086	Implant supported crown - predominantly base alloys
D6087	Implant supported crown - noble alloys
D6088	Implant supported crown - titanium and titanium alloys

1–10 of 18

1/2

Included CDT codes - group 4CDT

D6194	Abutment supported retainer for cast metal FPD - titanium and titanium alloys
D6075	Implant supported retainer for ceramic FPD
D6076	Implant supported retainer for FPD - porcelain fused to high noble alloys
D6098	Implant supported retainer - porcelain fused to predominantly base alloys
D6099	Implant supported retainer for FPD - porcelain fused to noble alloys
D6120	Implant supported retainer - porcelain fused to titanium and titanium alloys
D6077	Implant supported retainer for metal FPD - high noble alloys
D6121	Implant supported retainer for metal FPD - predominantly base alloys
D6122	Implant supported retainer for metal FPD - noble alloys
D6123	Implant supported retainer for metal FPD - titanium and titanium alloys

1–10 of 28

1/3

Diagnosis codes (reference)ICD-10

ICD-10-CM

Diagnoses 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.
Full-mouth imaging (or appropriate radiographs) and any additional diagnostic records needed to support medical necessity must be obtained and dated.
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.

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.

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.

Clinical considerationPeri-implant health of the retainers must be considered when evaluating cantilever designs.