CurrentColorado Rocky Mountain Health PlansPolicy DCP035.11

Space Maintainers (dental)

Governs use and coverage rationale for dental space maintainers to preserve arch space after premature loss of primary teeth; applies to Colorado Rocky Mountain Health Plans members under UnitedHealthcare standard and Medicare Advantage dental plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySpace Maintainers (dental)

Policy CodePolicy DCP035.11

Change TypeReferences updatedarchived prior version

Effective DateMar 1, 2026

Next Review Date

Key ActionVerify member-specific benefit plan and prior authorization requirements before submitting claims.

SourceLink

POLICY UPDATE CHANGES

Updated References section to reflect the most current information and archived previous policy version DCG035.10.

IndicatedIndication

4 listedContraindications

12 listedCDT codes

UpdatedReferences

Coverage Criteria

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inv-02: Contraindications

Not covered when any of the following contraindications are present:

Contraindications: Permanent tooth/teeth are close to eruption; member noncompliant or has poor oral hygiene; severe crowding already exists; space has already been lost.

These conditions contraindicate placement of a space maintainer.

The inclusion of a CDT/procedure code in this policy is for reference only and does not guarantee coverage. Benefit coverage is determined by the member-specific benefit plan document and applicable laws and mandates. Listing a code in this guideline does not imply any right to reimbursement or guarantee claim payment. Providers should verify coverage and any prior authorization requirements against the member’s contract before delivering services.

Placement of a space maintainer is considered not medically necessary when any of the listed contraindications apply. Contraindications include: when the permanent tooth/teeth are close to eruption; the member is noncompliant or has poor oral hygiene; severe crowding already exists; or the space has already been lost. Claims submitted under these circumstances may be denied.

Coding and Procedure Codes

Applicable CDT CodesCPT

D1510	Space maintainer - fixed - unilateral - per quadrant.
D1516	Space maintainer - fixed - bilateral, maxillary.
D1517	Space maintainer - fixed - bilateral, mandibular.
D1520	Space maintainer - removable - unilateral - per quadrant.
D1526	Space maintainer - removable - bilateral, maxillary.
D1527	Space maintainer - removable - bilateral, mandibular.
D1551	Re-cement or re-bond bilateral space maintainer - maxillary.
D1552	Re-cement or re-bond bilateral space maintainer - mandibular.
D1553	Re-cement or re-bond unilateral space maintainer - per quadrant.
D1556	Removal of fixed unilateral space maintainer - per quadrant.

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Provider Actions and Billing

Prior Authorization

Prior Authorization Required

Coverage decisions must follow the member-specific benefit plan. Prior authorization requirements vary by plan and may be required before providing space maintainer services. Providers must verify eligibility and benefits and obtain any required prior authorization from Colorado Rocky Mountain Health Plans before performing services.

Verify member eligibility and benefits prior to scheduling.
Obtain prior authorization when required by the member's benefit plan.

Denial Risk

Denial Triggers

Claims may be denied when space maintainers are provided despite contraindications or when documentation is insufficient. Common denial triggers include: providing a space maintainer when the permanent tooth is close to eruption; when the patient demonstrates poor oral hygiene or noncompliance; if severe crowding is present; or if the space has already been lost. Lack of prior authorization (when required) or failure to support medical necessity with clinical documentation can also result in claim denial.

Do not bill for space maintainers when contraindications listed above apply.
Include clinical documentation supporting the need for a space maintainer (clinical findings, radiographs, treatment notes).
Ensure prior authorization was obtained when required.

Billing Rule

Benefit and Coding Guidance

Providers must submit claims that reference the member-specific benefit plan and comply with applicable federal or state mandates. Use the applicable CDT procedure codes for space maintainers when billing. Inclusion of a code in this guidance does not guarantee coverage or payment; benefit coverage is determined by the member-specific plan. Review other applicable policies and guidelines that may affect coverage.

Reference member-specific benefit plan and any applicable federal or state mandates when submitting claims.
Bill appropriate CDT codes for space maintainers: D1510, D1516, D1517, D1520, D1526, D1527, D1551, D1552, D1553, D1556, D1557.
The presence of a code here is informational only and does not guarantee reimbursement.

Definitions

Space Maintainer — definition as a passive appliance usually cemented in place that holds teeth in position

DefinitionA passive appliance, usually cemented in place, that holds teeth in position.

Primary purposeMaintain arch length and prevent tooth movement after premature loss of primary teeth so permanent teeth can erupt in proper position.

Typical retentionUsually cemented (fixed) but may be removable depending on appliance type and clinical needs.

Clinical goalPrevent loss of arch width, length, or perimeter and reduce risk of malocclusion from space loss.

Background

Space maintainers are passive appliances, typically cemented in place, used to preserve arch length, width, and perimeter after premature loss of primary teeth. Their clinical purpose is to prevent adjacent teeth from drifting into the extraction site so permanent teeth can erupt into proper position, thereby reducing the risk of malocclusion and the potential need for more extensive orthodontic treatment.