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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield WI implant removable prosth…
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    CurrentBlue Cross Blue Shield - WisconsinPolicy 06-104

    Implant/Abutment Supported Removable Prosthetics

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    Defines clinical indications, required documentation, coding, and coverage criteria for implant- or abutment-supported removable dental prosthetics for Blue Cross Blue Shield - Wisconsin members.

    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyImplant/Abutment Supported Removable Prosthetics
    Policy CodePolicy 06-104
    Change TypeNo material changes
    Effective Date
    Last ReviewOct 29, 2024
    Next Review DateJan 1, 2025
    Key ActionObtain current (within 12 months), dated full mouth radiographic imaging and submit prior authorization or benefit verification with supporting clinical documentation when required.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsradiograph recency
    D6055,D6110–D6113,D6090example CDT codes
    aesthetic

    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.

    explicit exclusion
    no benefitmissing tooth clause
    inclusivetemporary prosthesis

    Coverage Criteria for Implant/Abutment Supported Removable Prosthetics

    Covered when ALL of the following are met

    Covered when ALL of the following are met:

    Clinical indications: Treatment is for replacement of missing teeth due to accidental traumatic injury, pathologic disorder resulting in extraction, congenitally missing teeth, or congenital disorders resulting in extraction.

    Refer to policy clinical indications and medical plan referral for accidental injury

    Documentation: Current (within 12 months), dated, diagnostic, pretreatment full mouth radiographic imaging is required.within 12 months

    Providers must have current (within 12 months), dated diagnostic pretreatment full mouth radiographic imaging; failure to provide may result in denial

    Implant stability: Implant body must be stable per dental clinical policy #06-101.

    See related policy #06-101 for implant body stability criteria

    Benefit/plan provisions: If the member's plan contains a missing tooth clause there is no benefit for replacement when implant/abutment supported removable prosthetics is treatment planned; if the plan does NOT contain a missing tooth clause, necessity will be determined and an alternate benefit may be applied per contract provisions.

    Contract-dependent; see alternate benefit provisions

    Provisional/temporary devices: Temporary or provisional implant/abutment supported removable prosthetics are considered inclusive with the final restoration.

    Delivery date and contract terms may apply

    Replacement of implant/abutment supported removable prosthetics for aesthetic reasons is not a covered benefit. Services planned solely to improve appearance without clinical indications do not meet coverage criteria and should not be billed as a covered service.

    When a member's plan includes a missing tooth clause, there is no benefit for replacement of the missing teeth when implant/abutment supported removable prosthetics is treatment planned. Providers must verify contract-specific provisions and direct members to any alternate benefits defined by the contract.

    As an additional emphasis of the coverage stance, replacement of implant/abutment supported removable prosthetics performed solely for aesthetic reasons remains not covered and should be considered not medically necessary under this policy.

    Coding and Imaging Requirements

    CDT codes (included but not exhaustive)CPT
    D6055Connecting bar - implant supported or abutment supported
    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
    D6090Repair implant supported prosthesis, by report
    Radiograph recency
    Required imagingCurrent, dated, diagnostic pretreatment full‑mouth radiographic imaging must be provided within 12 months of treatment.
    PurposeSupports medical necessity determination and is required for prior authorization or benefit verification when applicable.
    Denial riskFailure to provide current (within 12 months) full‑mouth radiographs may result in denial or incomplete services.

    Provider Requirements, Prior Authorization, and Denial Triggers

    Prior Authorization

    Obtain prior authorization / verify benefits and submit clinical documentation

    Prior authorization or verification of benefit applicability may be required per member contract and provider contract. Submit supporting clinical documentation (dated pretreatment full‑mouth radiographic imaging and any required narratives/chart notes) to demonstrate medical necessity when requesting authorization for CDT codes such as D6055, D6110–D6113, and D6090.

    • Prior authorization/benefit verification is contract dependent.
    • Include dated, pretreatment full‑mouth radiographs and clinical narratives as part of the authorization request.
    Note

    Apply alternate benefit provisions when contract allows

    When the member’s plan contains alternate benefit provisions, an alternate benefit may be applied to replace all missing teeth; whether this applies is contract dependent and will be determined per the plan.

    • Alternate benefit application is contract dependent.

    Background

    Implant/abutment supported removable prosthetics are dental appliances that the patient can remove and reinsert and are used to replace missing teeth resulting from trauma, pathologic disorders, or congenital conditions. These prostheses rely on implant or abutment support and require documentation of implant body stability per related dental policy. Temporary or provisional removable prostheses are considered inclusive with the final restoration for billing and coverage purposes.

    Definitions

    Removable (definition)
    DefinitionRemovable: able to be taken out by the patient, as opposed to an implant/abutment supported fixed denture or hybrid prosthesis which may only be removed by a dentist.
    Contrast to fixed prosthesisFixed prosthesis (denture/hybrid) is not removable by the patient and requires a dentist for removal.
    Clinical implicationPolicy applies to prosthetics that the patient can remove; fixed implant/abutment supported dentures are considered separately under related policy #06-101.
    Clinical indications
    Trauma-related lossReplacement for missing teeth due to accidental traumatic injuries (external blow or blunt trauma); note: claims should first be referred to the medical plan when applicable.
    Pathologic disorders
    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyImplant/Abutment Supported Removable Prosthetics
    Policy CodePolicy 06-104
    Change TypeNo material changes
    Effective Date
    Last ReviewOct 29, 2024
    Next Review DateJan 1, 2025
    Key ActionObtain current (within 12 months), dated full mouth radiographic imaging and submit prior authorization or benefit verification with supporting clinical documentation when required.
    SourceLink
    On This Page
    Coverage Criteria for Implant/Abutment Supported Removable ProstheticsCoding and Imaging RequirementsProvider Requirements, Prior Authorization, and Denial TriggersBackgroundDefinitions
  1. Determination made when plan does NOT contain a missing tooth clause whether the implant‑supported removable prosthetic is necessary or an alternate benefit applies.
    2. Documentation Required

    Document current diagnostic pretreatment full‑mouth radiographs and narratives

    Providers must have current (within 12 months), dated diagnostic pretreatment full‑mouth radiographic imaging on file; repair or replacement may also require a detailed narrative and/or chart notes depending on the provider contract.

    • Full‑mouth radiographs must be dated and within 12 months of treatment.
    • Detailed narratives/chart notes may be required for repair or replacement (contract dependent).
    Denial Risk

    Denial triggers for missing or incomplete documentation

    Claims may be denied if required current (within 12 months) full‑mouth radiographic imaging is not provided or if the subscriber fails to return for delivery; incomplete documentation for repair/replacement can also trigger denial.

    • Absence of dated, pretreatment full‑mouth radiographs (within 12 months) may result in denial.
    • Services may be considered incomplete if the subscriber does not return for delivery.
    • Lack of required detailed narrative/chart notes for repair or replacement (when contract dependent) may lead to denial.
    Replacement when teeth are lost because of pathologic disorders resulting in extraction.
    Congenital conditionsReplacement for congenitally missing teeth or congenital disorders resulting in extraction.
    Other clinical notesImplant body must be stable per dental clinical policy #06-101; temporary/provisional prostheses are considered inclusive with the final restoration.