CurrentEmpire BluecrossPolicy 06-001

Implant/ Abutment Supported Fixed Prosthetics Crowns and Fixed Partial Dentures

Guideline governing dental review and coverage considerations for implant- and abutment-supported crowns and fixed partial dentures for replacement of missing teeth under Empire BlueCross plans; applies to providers submitting claims and members covered by the dental plan.

Policy Summary

PayerEmpire Bluecross

PolicyImplant/ Abutment Supported Fixed Prosthetics Crowns and Fixed Partial Dentures

Policy CodePolicy 06-001

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionPrior to implant placement and restoration, complete a thorough dental evaluation, medical and dental history, full mouth imaging, and treatment plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsDocumentation timeframe

1 allowedCantilever FPD limitation

Not coveredAesthetic replacement stance

ExcludedThird molar exclusion

DiscouragedTooth-implant FPD caution

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Coverage Criteria — Medical Necessity, Limitations, and Exclusions

Medically Necessary Criteria

Covered when ALL of the following are met

Eligibility and clinical indication: Implant/abutment supported crowns and fixed partial dentures may be considered appropriate to replace missing teeth resulting from accidental traumatic injury, a pathologic disorder resulting in extraction, or congenital disorders/ congenitally missing teeth; treatment must conform to generally accepted standards of dental practice and not be primarily for convenience or cosmetic reasons.

See clinical indications (chunk 3) for standards.

Pre-operative evaluation: Prior to implant placement and restoration, a thorough dental evaluation, medical and dental history, full mouth imaging, and treatment plan must be completed.

chunk 4

Documentation: Current (within 12 months), dated diagnostic preoperative radiographic images are required; when radiographs do not clearly establish necessity include intra-oral photographs, treatment notes, and a narrative explaining any extraordinary circumstances.12 months

chunk 5

Alternate benefit / missing tooth clause: When a group contract contains a missing tooth clause there may be no benefit for replacement; when plans do not contain a missing tooth clause, alternate benefit provisions may be applied per group contract (an alternate, less costly benefit may be applied instead of implant-supported restoration).

chunks 4 and 5

Special circumstances: Replacement due to metal allergy/sensitivity will be considered only with submission of physician documentation and associated allergy report; inability to wear a removable appliance due to limited retention may qualify if documented by a letter of dental necessity, appropriate radiographic evidence, and a history of failed corrective procedures.

chunks 4 and 5

Limitations and Exclusions within Coverage

Limitations and procedural specifics

Third molar exclusion: Implant placement/restoration is not a covered benefit for third molar sites (group contract dependent).

chunks 3 and 4

Cantilever limitation: For cantilever implant/abutment supported fixed partial dentures, only one cantilever pontic may be an allowable benefit; peri-implant health of the retainers must be considered.

chunk 5

Aesthetic exclusions: Replacement of implant/abutment supported prosthetics for aesthetic reasons is not a covered benefit.

chunk 5

Tooth–implant supported FPD caution: Tooth-implant supported fixed partial dentures may not be considered for benefits based on evidence showing lower survival rates compared to solely implant-supported or solely tooth-supported FPDs; this provision is plan specific.

Dental implant supported restorations are intended to replace missing teeth; they are not appropriate when teeth are not missing. This explicitly includes replacement of third molars unless a group contract states otherwise. Providers should confirm the tooth is actually missing and that the indication meets the plan’s definition of generally accepted standards of dental practice before proposing an implant-supported restoration.

Additionally, replacement of implant/abutment supported prosthetics solely for aesthetic reasons is not a covered benefit. When proposing implants after accidental injury, pathologic extraction, or congenital absence, submit documentation that shows the clinical need rather than cosmetic intent (see documentation requirements for radiographs and supporting materials).

The policy considers replacement of multiple teeth in the same arch by implant-supported crowns or fixed partial dentures to be not medically necessary when less costly dental services can adequately restore occlusion and function, unless the member’s group contract specifically provides otherwise. Coverage determinations should compare alternate restorative options and costs per the group contract.

For tooth‑implant combination fixed partial dentures, evidence indicates a lower survival rate compared with solely implant‑supported or solely tooth‑supported FPDs; therefore benefits for tooth‑implant supported FPDs may be limited or denied and this provision is plan specific. When considering multiple-tooth replacement, include documentation demonstrating why less costly alternatives cannot provide adequate functional restoration.

Coding — CDT Codes for Surgical and Prosthetic Services

CDT (implant surgical codes)CDT

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

CDT (prosthetic, abutment, repair, pontic codes)CDT

D6056	Prefabricated abutment includes modification and placement
D6057	Custom fabricated abutment - includes placement
D6051	Interim implant abutment placement
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
D6113	Implant/abutment supported removable denture for partially edentulous arch mandibular
D6114	Implant/abutment supported fixed denture for dentulous arch maxillary
D6115	Implant/abutment supported fixed denture for dentulous arch mandibular

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Provider Actions — Evaluation, Documentation, and Billing Guidance

Documentation Required

Thorough dental evaluation required

Prior to implant placement and restoration, complete a thorough dental evaluation including a detailed medical and dental history, full‑mouth imaging, and a written treatment plan. Ensure records document current oral status and the rationale for implant therapy.

Must include full mouth imaging and a dated treatment plan
Current medical and dental history required

Prior Authorization

Accidental injury — refer to medical plan first

For cases of accidental injury (external blow or blunt trauma) resulting in missing teeth, refer claims first to the subscriber/employee's medical plan, as many medical plans cover dental services related to accidental injury. Document the referral and any medical plan determinations.

Refer to medical plan before billing Empire Bluecross for accidental‑injury related tooth replacement

Background

Implant- and abutment-supported crowns and fixed partial dentures are prosthetic options to replace missing teeth resulting from accidental traumatic injury, pathologic disorders leading to extraction, or congenital absence of teeth. Selection of implant-based solutions must conform to generally accepted standards of dental practice, taking into account the clinical indication, long-term peri‑implant health, and comparative survival data.

Prior to placement and restoration, a thorough dental evaluation, medical and dental history, full‑mouth imaging, and a treatment plan are required. Documentation must include current (within 12 months) dated diagnostic preoperative radiographs; when radiographs do not clearly establish necessity, provide intra‑oral photographs, treatment notes, and a narrative explaining extraordinary circumstances. Consideration should also be given to less costly alternatives and any group contract provisions (for example, missing tooth clauses or alternate benefit rules) that may affect coverage.

Definitions and Standards

Generally accepted standards of dental practice

Definition - basisStandards based on credible scientific evidence published in peer‑reviewed dental literature, specialty society recommendations/criteria, and the views of recognized dentists practicing in the relevant clinical area.

ScopeApplies to dental services provided to evaluate, diagnose, or treat a dental injury or disease; must be in accordance with generally accepted standards of dental practice in type, frequency, and extent.

Exclusions (teeth present)Implant/abutment supported prosthetics are not appropriate when teeth are not missing (including replacement of third molars).

Cost-effectiveness requirementNot medically necessary to replace multiple teeth in the same arch with implant‑supported restorations when less costly services can adequately restore occlusion (unless group contract specifies otherwise).

Purpose limitationServices must not be primarily for convenience or cosmetic reasons and must be considered effective for the patient's dental injury or disease.