CurrentBlue Cross Blue Shield - WisconsinPolicy 06-104

Implant/Abutment Supported Removable Prosthetics

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Wisconsin Policy 06-104 alerts

Get alerted when Policy 06-104 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy governing coverage and clinical criteria for implant- or abutment-supported removable dental prosthetics (removable by the patient) 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 30, 2025

Next Review DateJan 1, 2026

Key ActionObtain current (within 12 months), dated, diagnostic pretreatment full mouth radiographic imaging before proceeding.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsImaging recency

D6055, D6110-D6119, D6090CDT examples

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.

CurrentBlue Cross Blue Shield - WisconsinPolicy 06-104

Implant/Abutment Supported Removable Prosthetics

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Wisconsin Policy 06-104 alerts

Get alerted when Policy 06-104 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy governing coverage and clinical criteria for implant- or abutment-supported removable dental prosthetics (removable by the patient) 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 30, 2025

Next Review DateJan 1, 2026

Key ActionObtain current (within 12 months), dated, diagnostic pretreatment full mouth radiographic imaging before proceeding.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsImaging recency

D6055, D6110-D6119, D6090CDT examples

Coverage Criteria

Medical necessity criteria

Covered when ALL of the following are met (unless otherwise limited by contract):

1: Current (within 12 months), dated, diagnostic, pretreatment full mouth radiographic imaging is required.
2: Implant body must be stable (see dental clinical policy #06-101).
3: Indication: replacement of missing teeth resulting from accidental external blow/blunt trauma, pathologic disorder resulting in extraction, congenitally missing teeth, or congenital disorders resulting in extraction (claims for accidental injury should first be referred to the member's medical plan).
4: Delivery date: dependent on provider contract; the delivery date of the prosthetic is considered the date of delivery (contract dependent).
5: Temporary/provisional implant/abutment supported removable prosthetics are considered inclusive with the final restoration.
6: Repair or replacement requires a detailed narrative and/or chart notes (contract dependent).

ref':'b0_0

title':'Medical necessity criteria' }]}{

blocks_placeholder_removed_error

Replacement of implant/abutment supported removable prosthetics solely for aesthetic reasons is not a covered benefit under this policy.

Where the member's plan contains a missing tooth clause, there is no benefit for replacement of missing teeth when implant/abutment supported removable prosthetics are treatment planned. In plans without a missing tooth clause, the determination of necessity or application of an alternate benefit is contract dependent; plans with alternate benefit provisions may allow an alternate benefit to be applied to replace missing teeth.

Services will be considered incomplete with no benefit if the subscriber does not return for delivery of the prosthesis. Additionally, replacement of implant/abutment supported removable prosthetics that is performed for purely aesthetic reasons is not medically necessary under this policy.

Coding

CDT codes (examples listed)CPT

D6055	Connecting bar - implant supported or abutment supported
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 edentulous arch - maxillary
D6115	Implant/abutment supported fixed denture for edentulous arch - mandibular
D6116	Implant/abutment supported fixed denture for partially edentulous arch - maxillary
D6117	Implant/abutment supported fixed denture for partially edentulous arch - mandibular
D6118	Implant/abutment supported interim fixed denture for edentulous arch - mandibular

1–10 of 12

1/2

Provider Actions & Requirements

Prior Authorization

Prior Authorization Considerations

Prior authorization considerations — Delivery date, imaging, implant stability, and contract-dependent requirements.

Delivery date may be considered the date of delivery (contract dependent).
Prior authorization may require current diagnostic full-mouth radiographs (<=12 months).
Implant stability must be documented per dental clinical policy #06-101.
Repair/replacement requests may need detailed narrative/chart notes per contract.

Note

Alternate Benefit / Referral

Alternate benefit / referral — Alternate benefit provisions or missing tooth clauses may apply; replacements may be excluded.

Refer dental services related to accidental injury to the member's medical plan first.

Definitions

Removable — definition

DefinitionRemovable — a prosthetic that can be taken out by the patient (as opposed to a fixed implant/abutment supported denture or hybrid prosthesis that may only be removed by a dentist).

ContrastDistinct from fixed implant/abutment supported dentures or hybrids, which are removable only by a dentist.

ScopeApplies to implant- or abutment-supported prosthetics that the patient can independently remove and reinsert.

Clinical indications

Required indications — traumatic injuryReplacement of missing teeth resulting from accidental external blow or blunt trauma may be considered appropriate; such claims should first be referred to the member's medical plan for determination of medical coverage.

Pathologic disorders

Background

Implant/abutment supported removable prosthetics are prostheses that can be removed by the patient and are distinct from fixed implant-supported dentures or hybrids, which are removable only by a dentist. Appropriate clinical indications include replacement after accidental traumatic extraction/avulsion, extraction for a pathologic disorder, congenitally missing teeth, or congenital disorders resulting in extraction. Note that implant body stability is required per the related dental implant policy.