CurrentBlue Cross Blue Shield - WisconsinPolicy 06-104

Implant/Abutment Supported Removable Prosthetics

Governs clinical review criteria and coding guidance for implant- or abutment-supported removable dental prosthetics for Blue Cross Blue Shield - Wisconsin members; applies to providers requesting coverage determinations under the dental plan.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyImplant/Abutment Supported Removable Prosthetics

Policy CodePolicy 06-104

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review Date

Key ActionSubmit required documentation and applicable CDT codes when requesting prior authorization or benefit determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8criteria items

D6055,D6110-13,D6090example CDT codes

12 moimaging recency

01/01/2023publish date

Coverage Criteria for Implant/Abutment Supported Removable Prosthetics

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Clinical indications: Replacement of missing teeth resulting from accidental traumatic injuries to sound, natural teeth resulting in extraction; a pathologic disorder resulting in extraction; congenitally missing teeth; or congenital disorders of teeth resulting in extraction.

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

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

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Referral for accidental injury: Claims for replacement of missing teeth due to an external blow or blunt trauma must first be referred to the member's medical plan, as the medical plan may cover such replacements.

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Delivery date and temporaries: Delivery date is considered the date of delivery dependent on provider contract; temporary or provisional removable prosthetics are considered inclusive with the final restoration.

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Limited retention qualification: A patient's inability to wear a removable appliance due to limited retention may qualify for implant supported removable prosthetic placement when documented by a letter of dental necessity, supported by appropriate radiographic evidence, and a history of failed corrective procedures.

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Repair or replacement requests require a detailed narrative and/or chart notes; benefits are contract dependent.

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Aesthetic exclusion: Replacement for aesthetic reasons is not a covered benefit.

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Services performed primarily for patient or dentist convenience or those considered cosmetic are not considered medically or dentally necessary under generally accepted standards and therefore are not covered benefits. The plan reviews requests for implant/abutment supported removable prosthetics against contract requirements and generally accepted standards of dental care when determining coverage.

Coding and Diagnostic Imaging Requirements

CDT codes (informational)CDT

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
D6090	Repair implant supported prosthesis, by report

Recency of diagnostic imaging

Required timeframeCurrent (within 12 months), dated diagnostic pretreatment full mouth radiographic imaging is required.

PurposeDocumentation to support clinical indications and implant stability assessments for benefit determination.

Applies toProviders submitting requests for implant/abutment supported removable prosthetics prior to treatment delivery.

Provider Requirements, Authorization, and Denial Triggers

Prior Authorization

Prior Authorization and Codes

Prior authorization or pre-service review may be required. Submit all supporting clinical documentation at the time of request to allow for medical necessity review and determination of benefit coverage.

Include applicable CDT codes such as D6055, D6110, D6111, D6112, D6113, D6090 when known
Refer to dental clinical policy #06-101 for implant stability requirements

Step Therapy

Step Therapy / Treatment Sequencing

Step therapy or sequencing of treatments may be applied according to contract terms and clinical guidelines. Providers should document prior conservative or corrective procedures attempted and outcomes when relevant.

Document history of failed corrective procedures if using limited retention as justification for implant-supported removable prosthetic

Documentation Required

Required Documentation

Required documentation must be submitted with the authorization request or claim. Incomplete documentation may delay review or result in denial.

Current (within 12 months), dated, diagnostic pretreatment full mouth radiographic imaging is required
Letter of dental necessity when inability to wear a removable appliance due to limited retention is the indication, supported by radiographic evidence and history of failed corrective procedures
Detailed narrative and/or chart notes for repair or replacement requests
Delivery date documentation (delivery date is considered the date of service, subject to provider contract)
If tooth loss is due to accidental injury, refer claim to the member's medical plan first

Denial Risk

Denial Triggers

Services may be denied when contractual requirements or standards of care are not met or when services are cosmetic/non-essential.

Replacement for aesthetic reasons is not a covered benefit
Incomplete services (e.g., subscriber does not return for delivery) are not payable
Failure to provide required radiographs, narratives, or letters of necessity may trigger denial
Claims for accidental injury should be adjudicated by the medical plan if applicable; failure to refer appropriately may affect coverage

Background

Implant/abutment supported removable prosthetics are devices that can be removed by the patient and are used to replace missing teeth resulting from trauma, pathology, or congenital absence. Evaluation for coverage requires documentation that meets plan standards, including that the implant body must be stable (see dental clinical policy #06-101) and that pretreatment diagnostic imaging is current. These prosthetics may be appropriate when they restore function for missing teeth and when clinical indications and documentation requirements in the policy are satisfied.

Key clinical and administrative considerations include: current (within 12 months) dated pretreatment full‑mouth radiographic imaging; referral of claims for tooth replacement after accidental external trauma to the member's medical plan when appropriate; recognition that temporaries are inclusive with the final restoration; and that repair or replacement requests require a detailed narrative or chart notes and are contract dependent.

Definitions

Removable prosthetic (dental)

DefinitionA prosthetic that can be taken out by the patient, as opposed to prosthetics which can only be removed by a dentist.

ScopeRefers specifically to implant/abutment supported removable prosthetics addressed by this policy.

Relevance to coveragePolicy review evaluates these services against contract requirements and generally accepted standards of dental care.

Generally accepted standards of dental practice

DefinitionStandards based on credible peer-reviewed scientific evidence, specialty society recommendations, views of recognized dentists in the clinical area, and other relevant credible sources.

Use in policyServices are judged against these standards to determine medical/dental necessity and appropriateness under contract terms.

ImplicationFailure to meet these standards may result in denial or classification as not medically/dentally necessary.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyImplant/Abutment Supported Removable Prosthetics

Policy CodePolicy 06-104

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review Date

Key ActionSubmit required documentation and applicable CDT codes when requesting prior authorization or benefit determination.

SourceLink

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