CurrentEmpire BluecrossPolicy 06-104

Implant/Abutment Supported Removable Prosthetics

Defines clinical review criteria and coding guidance for implant/abutment supported removable dental prosthetics and governs review for plan members receiving these prosthetics under Empire Bluecross dental benefits.

Policy Summary

PayerEmpire Bluecross

PolicyImplant/Abutment Supported Removable Prosthetics

Policy CodePolicy 06-104

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review Date

Key ActionSubmit pretreatment full mouth radiographs (within 12 months) and supporting documentation including a letter of dental necessity when limited retention is claimed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 codesCoding references included

12 moRadiograph recency

Letter + imagesDocumentation required

ExcludedAesthetic replacement

Coverage Criteria

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Clinical indications

Imaging requirement: 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 (see dental clinical policy #06-101).
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Limited retention qualification: Patient inability to wear a removable appliance due to limited retention may qualify; requires a letter of dental necessity from the treating provider, appropriate radiographic evidence, and documentation of a history of failed corrective procedures.
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Operational/Contract-dependent rules

Other coverage-related rules

Temporary prosthetic: A temporary or provisional dental implant removable prosthetic is considered inclusive with the final restoration.

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Delivery date: Dependent on provider contract, the delivery date of implant supported removable prosthetics is considered the date of delivery.

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Repair/replacement: Repair or replacement of implant supported removable prosthetics requires a detailed narrative and/or chart notes; benefits are contract dependent.

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Replacement of implant/abutment supported prosthetics for purely aesthetic reasons is explicitly excluded and is not a covered benefit under this policy. This exclusion applies regardless of clinical context or procedural coding; benefits for such replacements are not payable when the sole rationale is cosmetic appearance.

Coding

CDT codes included (informational)CDT

D605S	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

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Submission Requirements

Claims require prior authorization and submission of supporting documentation, including diagnostic imaging and clinical records. Submit pretreatment radiographs (current within 12 months) and any required letters of dental necessity with the prior authorization request.

Pretreatment full‑mouth radiographs dated within 12 months
Letter of dental necessity when limited retention is claimed
Document prior failed corrective procedures when applicable
Detailed narrative/chart notes for repair or replacement requests (benefits are contract dependent)

Denial Risk

Failed Conservative Therapy Requirement

When limited retention is cited as the reason for implant‑supported removable prosthetic placement, providers must document prior failed conservative or corrective therapies.

Document specific corrective procedures attempted and dates
Include chairside notes and outcomes of prior therapies

Documentation Required

Required Documentation

Provide current (within 12 months) dated diagnostic pretreatment full mouth radiographic imaging with submissions. For limited retention cases, include a letter of dental necessity and radiographic evidence supporting the claim.

Full‑mouth radiographs (dated within 12 months)
Letter of dental necessity for limited retention cases
Radiographic evidence demonstrating limited retention

Note

Coding Inclusion Is Informational

The list of procedure and diagnosis codes in this policy is informational only. Inclusion or exclusion of codes does not guarantee coverage or reimbursement; payable benefits are determined by the member's contract and plan benefits in effect at the time of service.

Background

Implant/abutment supported removable prosthetics are devices that replace missing teeth and are intended to be removable by the patient or clinician. They are considered appropriate when tooth loss results from accidental traumatic injury, pathologic disorder, congenitally missing teeth, or other congenital disorders of teeth.

When evaluating these prosthetics, the plan requires documentation that they meet standard clinical criteria: current (within 12 months), dated, diagnostic pretreatment full mouth radiographic imaging; confirmation that the implant body is stable (see dental clinical policy #06-101); and when limited retention is cited as the indication, a letter of dental necessity, appropriate radiographic evidence, and a history of failed corrective procedures must be submitted. Benefits and any delivery/repair rules remain contract dependent.

Definitions

Removable prosthetic — Definition

DefinitionA prosthetic that can be taken out by the patient (as opposed to implant/abutment supported removable prosthetics which may only be taken out by a dentist).

ContrastImplant/abutment supported removable prosthetics may require dentist removal and are distinguished from patient‑removable prosthetics.

ScopeThis definition is applied when reviewing benefits for implant/abutment supported removable prosthetics under the plan's contractual requirements.

Generally accepted standards of dental practice — Definition

DefinitionServices a dentist provides exercising prudent clinical judgment to evaluate, diagnose, or treat dental injury or disease that are in accordance with generally accepted standards of dental practice.

Key characteristicsAppropriate in type, frequency, and extent; considered effective for the patient’s condition; not primarily for convenience; not cosmetic; and not more costly than an alternative service.

Policy applicationThe plan reviews services against these standards to determine medical/dental necessity and contractual coverage; meeting clinical necessity does not guarantee plan benefit payment.

Policy Summary

PayerEmpire Bluecross

PolicyImplant/Abutment Supported Removable Prosthetics

Policy CodePolicy 06-104

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review Date

Key ActionSubmit pretreatment full mouth radiographs (within 12 months) and supporting documentation including a letter of dental necessity when limited retention is claimed.

SourceLink

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