CurrentEmpire BluecrossPolicy 06-001

Implant Fixed Prosthetics Crowns and Fixed Bridges

Governs medical necessity review and coverage considerations for implant-supported crowns, abutment-supported crowns, and implant-supported fixed partial dentures for replacement of missing teeth for Empire BlueCross members.

Policy Summary

PayerEmpire Bluecross

PolicyImplant Fixed Prosthetics Crowns and Fixed Bridges

Policy CodePolicy 06-001

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review Date

Key ActionObtain a treatment plan and diagnostic radiographs within the prior 12 months before implant placement and restoration.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleprocedure codes (informational)

12 monthsradiograph requirement

may denymissing-tooth clause

inclusivetemporaries

Coverage and Medical Necessity Criteria

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Clinical indications: Missing teeth are present and replacement is due to accidental traumatic injury resulting in extraction, a pathologic disorder resulting in extraction, congenitally missing teeth, or congenital disorders of teeth resulting in extraction.

See chunk 2 for list.

Pre-procedure evaluation: A thorough dental exam, medical/dental history, full mouth imaging, treatment plan, and diagnostic radiographic images within the preceding 12 months must be completed prior to implant placement and restoration.radiographs within 12 months

Additional intra-oral photographs and narrative required if radiographs do not clearly document necessity (chunk 5).

Cost-effectiveness/alternate treatment: Implant-supported prosthetics are considered only when they meet generally accepted standards of dental care and when less costly dental services cannot adequately restore occlusion/function; alternate benefit provisions may apply per group contract.

Chunk 2 and 5 describe alternate benefit/less costly options.

Specific exclusions/plan limits: Replacement for non-missing teeth, replacement of third molars, and multiple teeth replacement in same arch may be not medically necessary or excluded depending on group contract (missing tooth clauses).

Chunk 2,4,5.

Temporary/provisional inclusion: Temporary or provisional implant-supported prosthetics are considered inclusive with the final restoration (no separate benefit).

Chunk 4.

Conditional/plan-specific coverage

Situations where coverage is conditional or plan-specific:

Tooth-implant supported FPD: Tooth-implant supported fixed partial dentures may not be considered for benefits based on evidence of lower survival compared with solely implant- or tooth-supported FPDs; this is plan specific.

Chunk 5.

Inability to wear removable appliance: A documented inability to wear a removable appliance due to limited retention may qualify a patient for implants if supported by a letter of dental necessity, radiographic evidence, and history of failed corrective procedures.

Chunk 5.

Metal allergy/sensitivity: Replacement due to metal allergy/sensitivity will be considered only with physician documentation and an associated allergy report.

Chunk 4.

Dental implant placement and restoration are intended to replace missing teeth. Implant-supported crowns, abutment-supported crowns, and implant/abutment-supported fixed partial dentures are not appropriate where teeth are not missing; this explicitly includes replacement of third molars. Plans that contain a missing-tooth clause or alternate-benefit provisions may further restrict or deny benefits for replacement of missing teeth, and implant prosthetic restoration may be subject to contract limitations or alternate benefit application.

Prior authorization and documentation requirements apply: diagnostic radiographic images within the preceding 12 months are required to establish necessity. When radiographs do not clearly document need, include intra-oral photographs, patient treatment notes, and a narrative explaining extraordinary circumstances. Repair or replacement of existing implant prosthetics (e.g., fractured porcelain, loose/broken abutment or screw) requires a detailed narrative and is benefit- and contract-dependent.

Replacement of multiple teeth in the same arch with implant-supported crowns or implant/abutment-supported fixed partial dentures is considered not medically necessary when less costly dental services can adequately restore occlusion and function. This determination is subject to group contract provisions and alternate benefit rules; for plans without a missing-tooth clause an alternate benefit may be applied instead of implant coverage.

Tooth-implant combination fixed partial dentures have been shown in meta-analyses to have lower survival rates than solely implant- or solely tooth-supported FPDs; coverage for tooth-implant supported FPDs is therefore plan specific and may be excluded by some contracts.

Relevant Procedure and Diagnosis Codes

Informational surgical implant codesCDT

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

Informational surgical implant codes (additional note)CDT

No codes listed

Informational prosthetic, abutment, and repair codesCDT

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
D6058	Abutment supported porcelain/ceramic crown
D6059	Abutment supported porcelain fused to metal crown (high noble metal)
D6065	Implant supported porcelain/ceramic crown
D6066	Implant supported crown porcelain fused to high noble alloys

1–10 of 13

1/2

Pontic and retainer codesCDT

D6075	Implant supported retainer for ceramic FPD
D6120	Implant supported retainer - porcelain fused to titanium and titanium alloys
D6205	Pontic - indirect resin based composite
D6210	Pontic cast high noble metal
D6245	Pontic porcelain/ceramic

Diagnosis coding noteICD-10

ICD-10-CM

Diagnoses for dental diseases and conditions (see CDT book)

Provider Requirements, Documentation, and Denial Risks

Prior Authorization

Pre-treatment review required — Prior to implant placement and restoration

Prior to implant placement and restoration, a treatment plan and requisite imaging/diagnostics must be completed; benefits and applicability assessed. Submit a thorough dental exam, medical/dental history, full mouth imaging, and treatment plan before proceeding. When implant necessity is not clear on radiographs, include intra-oral photos, patient treatment notes, and a narrative explaining extraordinary circumstances.

Diagnostic radiographs within 12 months
Full mouth imaging and treatment plan
Intra-oral photos and narrative when radiographs are nondiagnostic

Denial Risk

Alternate/less-costly options — Consider less costly dental services first

Consider less costly dental services that adequately restore occlusion and function before approving implant-supported restorations. When the plan includes an alternate/alternate benefit provision, an alternate benefit may be applied to replace missing teeth; implant benefits may be limited or denied if less costly options are clinically appropriate.

Evaluate removable partial denture, fixed tooth-supported prosthesis, or other restorative options first
Check group contract for alternate benefit / missing-tooth clause applicability

Documentation Required

Required clinical documentation — Limited retention and allergy documentation

If a patient is unable to tolerate a removable appliance due to limited retention, submit a letter of dental necessity from the treating provider supported by appropriate radiographic evidence and a history of failed corrective procedures. For replacements due to metal allergy/sensitivity, include physician documentation and the associated allergy report.

Letter of dental necessity describing limited retention and prior corrective attempts
Radiographic evidence supporting limited retention
Physician allergy documentation and allergy report for metal sensitivity cases

Denial Risk

Denial triggers — Missing-tooth and third molar exclusions

Replacement is not appropriate where teeth are not missing; plans with a missing-tooth clause may deny benefit for replacement of missing teeth. Implant placement/restoration is not a covered benefit for third molar sites.

Do not submit implant requests for non-missing teeth or third molar sites
Verify whether the group contract contains a missing-tooth clause

Background

Implant-supported crowns and fixed partial dentures are restorative options used to replace teeth lost because of accidental traumatic injury, pathologic disorders leading to extraction, or congenital absence or congenital dental disorders resulting in extraction. These prostheses restore occlusion and function when less costly alternatives are inadequate.

Clinical decision-making should follow generally accepted standards of dental practice, which include peer-reviewed scientific evidence, specialty society recommendations, and the views of experienced practitioners. Tooth-implant combination prostheses demonstrate lower survival in the literature compared with solely implant- or tooth-supported restorations, and this clinical evidence informs plan-specific coverage decisions.

Standards and Definitions

Generally accepted standards of dental practice

DefinitionStandards based on credible peer-reviewed dental literature, specialty society recommendations, expert practitioner views, and other credible sources guiding appropriate type, frequency and extent of dental services.

ScopeApplies to dental implant-supported crowns, implant/abutment-supported crowns, and implant/abutment-supported fixed partial dentures used to replace missing teeth.

Key requirementServices must be in accordance with generally accepted standards of dental practice — i.e., appropriate in type, frequency, and extent, effective for the patient’s condition, not primarily for convenience, not cosmetic, and not more costly than an adequate alternative.

Evidence sourcesIncludes credible scientific evidence published in peer‑reviewed dental literature, specialty society recommendations, and views of recognized dentists practicing in the clinical area.

Exclusion noteProcedures are not appropriate where teeth are not missing, including replacement of third molars; replacement of multiple teeth in the same arch may be not medically necessary when less costly services can adequately restore occlusion/function (unless group contract specifies otherwise).