CurrentEmpire BluecrossPolicy 06-001

Dental Clinical Policy

Defines clinical indications, documentation and contractual criteria for coverage determination of dental implant-supported crowns, implant abutment crowns, and implant-supported fixed partial dentures; includes coding list for related CDT/D codes and notes plan/contract limitations.

Policy Summary

PayerEmpire Bluecross

PolicyDental Clinical Policy

Policy CodePolicy 06-001

Change TypeRevised (Annual Review)

Effective DateJan 1, 2021

Next Review Date

Key ActionComplete a thorough dental exam, medical/dental history, full mouth imaging and treatment plan and submit diagnostic radiographs (<=12 months) and supporting documentation prior to implant placement.

SourceLink

POLICY UPDATE CHANGES

Policy status shows 'Revised' with last review 12/05/2020 (Annual Review).

MultipleRelevant CDT codes listed

ConditionalGroup contract dependent

ExcludedThird molar implants

Coverage Summary

Policy #06-001 (Subject: Implant-supported crowns and fixed bridges (dental)) is CURRENT and effective 2021-01-01. It governs implant-supported prosthetic restorations and defines clinical indications, documentation and contractual criteria for coverage determination of dental implant-supported crowns, implant abutment crowns, and implant-supported fixed partial dentures.

Surface quick-reference

Policy Number06-001

PayerEmpire Bluecross

Policy TitleImplant-supported crowns and fixed bridges (dental)

Effective Date2021-01-01

Last Review2020-12-05

Coverage Stancemixed

Scope SummaryDefines clinical indications, documentation and contractual criteria for coverage determination of dental implant-supported crowns, implant abutment crowns, and implant-supported fixed partial dentures; includes coding list for related CDT/D codes and notes plan/contract limitations.

Clinical Indications and Medical Necessity

Clinical Indications / Medical Necessity

Dental implant-supported crowns, implant and abutment supported crowns, or implant and/or abutment supported fixed partial dentures may be considered appropriate when ALL of the following apply (unless group contract specifies otherwise):

ref": "b1_0", "title": "Clinical Indications / Medical Necessity"

ERROR_PLACEHOLDER

Exclusions / Not Appropriate

Services are NOT appropriate when ANY of the following apply:

ANY of the following

Teeth are not missing (replacement of non-missing teeth is not appropriate)
Replacement of third molars using implant-supported crowns or fixed partial dentures
Replacement of multiple teeth in same arch when less costly dental services can adequately restore occlusion (unless group contract specifies otherwise)
Tooth-implant supported fixed partial dentures may not be considered for benefits due to lower survival rate compared to solely implant-supported or solely tooth-supported FPDs
Provision is plan specific.
Implant placement/restoration for developmental or congenital defects (except congenitally missing teeth when covered by group contract)
If subscriber does not return for cementation, service is considered incomplete and no benefit is payable

Additional Operational Criteria / Documentation and Repair

ALL of the following

Temporary or provisional implant-supported prostheses are considered inclusive with the final restoration
Replacement due to metal allergy/sensitivity requires physician documentation and associated allergy report
Repair/replacement of implant prosthetics (fractured porcelain, loose abutment/screw, broken screw, etc.) requires a detailed narrative and is contract dependent
Delivery date of implant-supported crowns/FPDs is considered the date of initial delivery, dependent on provider contract
For plans without a missing tooth clause, determination will be made whether implant restoration is necessary or an alternate benefit applies; alternate benefit provisions are group contract dependent

Relevant CDT / D Codes

Relevant CDT/D codes (informational list)mixed

D6010	Surgical placement of implant body; endosteal implant
D6011	Surgical access to an implant body (second stage implant surgery)
D6013	Surgical placement of mini implant
D6056	Prefabricated abutment; includes modification and placement
D6057	Custom fabricated abutment; includes placement
D6051	Interim abutment
D6052	Semi-precision attachment abutment
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

1–10 of 66

1/7

Provider Actions & Documentation Requirements

Documentation Required

Preoperative documentation and imaging

Complete a thorough dental exam, medical and dental history, full mouth imaging and treatment plan prior to implant placement. Submit diagnostic radiographic images obtained within the preceding 12 months to document necessity. If the radiographs are not diagnostic, include intra-oral photographs, patient treatment notes, and a narrative explaining any extraordinary circumstances that necessitate implant prosthetic coverage.

Diagnostic radiographs must be within the preceding 12 months.

Prior Authorization

Medical plan referral for traumatic injury cases

Refer claims for replacement of teeth lost due to an external blow or blunt trauma to the subscriber/employee's medical plan first, since most medical plans may cover dental services related to accidental injury.

Documentation Required

Allergy documentation for metal sensitivity

Submit physician documentation and the associated allergy report to support replacement of implant prosthetics when metal allergy or sensitivity is cited.

Documentation Required

Letter of dental necessity for limited retention

Provide a letter of dental necessity with supporting radiographic evidence and a history of failed corrective procedures when inability to wear a removable appliance due to limited retention is cited as the reason for implant placement.

Billing Rule

Final delivery / cementation required

If the subscriber does not return for cementation (final delivery), the service is considered incomplete and no benefit is payable.

Documentation Required

Repair/replacement narratives

Provide a detailed narrative for repair or replacement of implant prosthetics (for example, fractured porcelain, loose abutment, loose or broken screw). Coverage for such repairs or replacements is contract dependent.

Background and Evidence

This policy applies to replacement of missing teeth with implant-supported crowns, implant/abutment supported crowns, and implant-supported fixed partial dentures and frames coverage decisions around whether such services meet generally accepted standards of dental care and contract provisions.

Coverage decisions are driven by demonstration of clinical necessity (per standards based on peer-reviewed evidence and specialty recommendations), cost-effectiveness/alternate benefit considerations under the member's group contract (including missing tooth clauses), and contract-specific exclusions or limitations such as third molar sites excluded and plan-dependent rules for replacement of multiple teeth in the same arch.

References include peer-reviewed clinical studies, specialty society materials and coding resources: American Academy of Periodontology publications and position statements, systematic reviews and clinical studies on implant outcomes and management, and the American Dental Association CDT coding guidance.

Specifically cited sources in the policy references list include AAP position papers and reviews, multiple long-term implant outcome studies and systematic reviews, and the ADA CDT code listings used for the informational code group.

Definitions

TermGenerally accepted standards of dental practice

DefinitionStandards that are based on credible scientific evidence published in peer-reviewed dental literature generally recognized by the practicing dental community; specialty society recommendations/criteria; the views of recognized dentists practicing in the relevant clinical area; and any other relevant factors from credible sources.

Policy Summary

PayerEmpire Bluecross

PolicyDental Clinical Policy

Policy CodePolicy 06-001

Change TypeRevised (Annual Review)

Effective DateJan 1, 2021

Next Review Date

SourceLink

On This Page

OpenPayer

Dental Clinical Policy

Coverage Summary

Clinical Indications and Medical Necessity

Relevant CDT / D Codes

Provider Actions & Documentation Requirements

Background and Evidence

Revision History