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Dental Implants
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Defines medical necessity and coverage conditions for subperiosteal, endosteal, and transosteal dental implants when benefits are available under Cigna-administered health plans; intended for providers and reviewers determining coverage eligibility.
Added clarifying verbiage regarding congenital defects (e.g., cleft palate).
Revised policy statements regarding cancer to include both malignant or benign tumors/lesions.
Revised statements regarding referring to benefit plan language.
Coverage and Medical Necessity Criteria
Reconstructive Dental Implants (medically necessary criteria)
Covered when ALL of the following are met
Reconstructive implants medical necessity
- Acceptable underlying conditions: i. in an individual with a congenital defect (e.g., cleft palate) or developmental malformation which interferes with function; ii. following an accidental injury to sound natural teeth (chewing injuries excluded); iii. loss of natural teeth due to oral tumor or lesion (benign or malignant) which interferes with function; iv. head or neck tumor or lesion (benign or malignant) AND EITHER of the following: 1) removal of a tumor; 2) a cancer related episode of care that results in reconstruction.
Chewing injuries are not considered accidental injuries.
Reconstructive implant coverage criteria
Covered when ALL of the following are met
Based on AAOMS/ACP descriptions of reconstructive indications; cosmetic use is distinguished separately.
Per AAOMS and ACP guidance.
Implant placement may be precluded or delayed if active disease or inadequate supporting tissues exist.
Radiotherapy and grafted irradiated bone increase implant failure risk and osteoradionecrosis is a possible complication.
Evidence shows higher hazard ratio for implant failure in those with prior periodontitis over 5–10 years.
Subperiosteal, endosteal, and transosteal implants are not medically necessary when used for any indication other than the reconstructive indications described in this policy. Examples of noncovered indications include tooth loss due to non‑cancer related decay, treatment of periodontal disease, and procedures performed for cosmetic reconstruction.
Implant placement performed primarily to improve appearance in the absence of functional impairment is considered cosmetic and is distinguished from reconstructive indications. Reconstructive use is defined as implant therapy intended to restore function or rehabilitate structural oral/maxillofacial defects (for example, congenital anomalies, trauma, or tumor resection); cosmetic indications without functional need are not eligible under the reconstructive criteria.
Policy statements have been revised to clarify that coverage determinations should be made with reference to the member’s individual benefit plan language. Providers seeking authorization or coverage should confirm plan‑specific benefits and prior authorization requirements in addition to meeting the clinical criteria in this policy.
When the indication for implant placement is non‑cancer related decay, periodontal disease, or solely for cosmetic reasons, subperiosteal, endosteal, and transosteal implants are considered not medically necessary. The policy highlights limited evidence supporting routine implant use for these conditions and requires reconstruction‑focused indications for coverage.
Implant placement should not proceed while active disease or inadequate supporting tissues (eg, insufficient bone volume/quality) remain unaddressed; such conditions may preclude or delay implantation until they are resolved or appropriately managed. Documentation must demonstrate that underlying conditions compromising healing have been evaluated and treated or that a documented plan for augmentation is in place.
Some sections of the source document do not restate explicit "not medically necessary" language for every potential scenario; however, the policy’s exclusions and not‑medically‑necessary statements are summarized elsewhere in the document and providers should refer to those sections and the member’s benefit plan for definitive coverage determinations.
Billing and Coding
| 21244 | Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate). |
| 21245 | Reconstruction of mandible or maxilla, subperiosteal implant; partial. |
| 21246 | Reconstruction of mandible or maxilla, subperiosteal implant; complete. |
| 21248 | Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial. |
| 21249 | Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete. |
| DZE | FDA product code referenced |
| ELE | FDA product code referenced |
| MDL | FDA product code referenced |
| NRQ | FDA product code referenced |
| DZE | FDA product code referenced |
| ELE | FDA product code referenced |
| MDL | FDA product code referenced |
| NRQ | FDA product code referenced |
What Providers Must Do
Prior authorization and coding — submit appropriate CPTs and medical necessity
If the member's benefit plan provides coverage, submit the request using the applicable CPT procedure codes (21244, 21245, 21246, 21248, 21249) and include medical necessity documentation demonstrating the case meets policy criteria; reimbursement is only provided when services are submitted in accordance with the policy's covered diagnosis and procedure codes.
- Use the most appropriate codes as of the date of submission.
- Include evidence that natural teeth cannot be repaired and conventional prostheses are not feasible when claiming medical necessity.
Pre-procedure oncology consultation for irradiated patients
For patients with prior head and neck radiotherapy, consult the treating radiation oncologist before performing invasive dental procedures and document the consultation and timing considerations (for example, evidence that waiting >12 months post‑radiation was considered), as recommended by oncology guidelines.
- Document radiation history, oncology consultation, and rationale for timing of implantation.
- Record any discussion of elevated implant failure risk and osteoradionecrosis.
Check member benefit plan language for prior authorization
Refer to the member's specific benefit plan language for prior authorization and coverage requirements; policy guidance may be superseded by the customer's plan document and benefit terms.
- Coverage determinations require review of the applicable benefit plan document (e.g., EOC, SPD).
- In case of conflict, the benefit plan document supersedes the Coverage Policy.
Submit plan-coverage evidence and medical necessity documentation
When requesting coverage, provide documentation that the plan covers the service and that the case meets the policy's medical necessity criteria (for example, evidence that natural teeth cannot be repaired and conventional bridgework or partial dentures are not feasible).
- Attach clinical records showing inability to restore or replace teeth with conventional prostheses.
- Include relevant diagnostic and treatment history to support reconstructive indication.
When implants are primarily cosmetic, document alternatives and justification
If implant therapy is planned primarily to improve appearance without functional impairment, consider and document alternative non‑reconstructive options because such placement is classified as cosmetic and not reconstructive.
- Document functional impairment or reconstructive need to support coverage.
- If cosmetic only, note that placement is considered cosmetic and may not meet medical necessity criteria.
Document comprehensive evaluation and treatment planning
Provide documentation of comprehensive patient evaluation and treatment planning that addresses feasibility and risk factors for implant therapy; include assessment of bone volume/quality, oral and systemic health, and identification of conditions that could compromise healing.
- Document assessment of bone volume/quality and any planned augmentation.
- Record risk factors or conditions (e.g., periodontal disease history) that affect implant candidacy.
Required documentation showing plan coverage and medical necessity
Submit documentation demonstrating the plan provides coverage for the service and that the specific case meets the policy's reconstructive criteria, including prosthodontic‑driven planning (number, type, and position of implants).
- Include prosthodontic treatment plan specifying implant number, type, and position.
- Attach evidence that conventional prostheses are not feasible or adequate.
Document comprehensive clinical evaluation and interdisciplinary planning
Ensure clinical records reflect an interdisciplinary evaluation and prosthodontic‑driven treatment plan—document functional impairment, bone assessments, prior surgery or radiation history, and consultations (including radiation oncology when applicable).
- Include prosthodontic-driven planning for implant number, type, and position.
- Document consultations and coordination among surgical, prosthodontic, and oncology teams as applicable.
Document congenital defects and tumor/lesion pathology when seeking coverage
When coverage is sought for congenital defects or tumor-related tooth loss, document the congenital anomaly (e.g., cleft palate) or tumor/lesion pathology (benign or malignant) and how it causes functional impairment requiring reconstructive implant therapy.
- Attach pathology or operative reports for tumors/lesions indicating benign or malignant status.
- Document congenital defect details and functional impact (e.g., cleft palate).
Denial risk: missing covered diagnosis or unmet medical necessity
Services billed without a covered diagnosis or without meeting the policy's medical necessity criteria will be denied; implants for tooth loss due to non‑cancer decay, periodontal disease, or purely cosmetic reconstruction are considered not medically necessary and subject to denial.
- Do not bill implant procedures under this policy for non‑cancer-related decay, periodontal disease, or cosmetic-only indications.
- Ensure submitted diagnosis codes match a covered reconstructive indication.
Do not place implants when active disease or inadequate tissues remain — document resolution
Do not proceed with implant placement until active oral disease is resolved and supporting tissues are adequate; failing to document resolution of conditions that compromise healing (for example, active infection or inadequate bone) can preclude coverage or lead to denial.
- Document treatment of active disease and plans for augmentation if needed prior to implantation.
- Include objective assessments of tissue adequacy (imaging, clinical measurements).
Reference the member's benefit plan language for coverage decisions
Make coverage determinations in reference to the member's benefit plan language; failure to follow the plan document and its requirements may result in denial even if the service otherwise meets the Coverage Policy.
- Review the applicable Group Service Agreement, Evidence of Coverage, or SPD for plan-specific exclusions or requirements.
- When in doubt, confirm prior authorization requirements per the benefit plan.
Background and Context
Dental implants (including subperiosteal, endosteal, and transosteal devices) are prosthetic constructs placed on or within the mandible or maxilla to provide retention and support for a dental prosthesis. Their primary reconstructive role is to restore oral function via osseointegration and to rehabilitate structural defects resulting from congenital anomalies, trauma, or tumor‑related resection when natural teeth cannot be repaired or replaced with conventional prostheses. Device selection and timing consider bone quantity and quality and may require adjunctive procedures such as bone grafting or interdisciplinary planning.
Definitions
Policy Changes
Revised statements to clarify referral to member benefit plan language; added clarifying verbiage regarding congenital defects (e.g., cleft palate); and revised cancer-related statements to include both benign and malignant tumors/lesions.
Policy established (new policy effective date recorded in source).
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