CurrentEmpire BluecrossPolicy 06-104

Implant Supported Removable Prosthetics

Policy governing clinical review and criteria for implant-supported removable dental prosthetics (patient-removable) for Empire BlueCross members; applies to dentists and reviewers evaluating medical/dental necessity under contract terms.

Policy Summary

PayerEmpire Bluecross

PolicyImplant Supported Removable Prosthetics

Policy CodePolicy 06-104

Change TypeNo material changes

Effective Date01/01/2022

Next Review Date

Key ActionSubmit current full mouth radiographic imaging and required documentation with any prior authorization or review request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D6055,D6110-13example CDT codes listed

1required current full mouth radiographic imaging

Documentationletter of dental necessity required

Contractcontract-dependent

Coverage criteria and exclusions

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Indications: Implant-supported removable prosthetics may be considered appropriate for replacement of missing teeth resulting from accidental traumatic injuries to sound, natural teeth from an external blow resulting in extraction; pathologic disorder resulting in extraction; congenitally missing teeth; or congenital disorders of teeth resulting in extraction.

Services must meet generally accepted standards of dental practice.

Imaging: Current full mouth radiographic imaging is required.

Implant stability: Implant body must be stable (see dental clinical policy #06-101).

Prior medical review for trauma: Replacement of missing teeth resulting from an external blow or blunt trauma must first be referred to the subscriber/employee's medical plan to determine medical coverage.

The medical plan may cover replacement for accidental injury; benefits are contract dependent.

Documentation for limited retention: If inability to wear a removable appliance due to limited retention is claimed, a letter of dental necessity from the treating provider, appropriate radiographic evidence, and a history of failed corrective procedures are required.

Repair or replacement requires detailed narrative and/or chart notes; benefits are contract dependent.

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

Inclusion and separate billing are dependent on provider contract.

Services that are primarily cosmetic or performed for convenience are excluded from medical or dental necessity determinations under this policy. Coverage determinations for implant-supported removable prosthetics remain dependent on the member's contract, and a finding of medical necessity does not guarantee that a service is a covered, payable benefit under the dental plan. Providers should verify member benefits and contract terms prior to treatment.

Relevant procedure and diagnosis codes

CDT including but not limited toCDT

D6055	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
Unlisted	Repair implant supported prosthesis, by report

Diagnosis codesICD-10

ICD-10-CM

Diagnoses for dental diseases and conditions: See the current CDT code book for details

Diagnosis codesICD-10

ICD-10-CM

Diagnoses for dental diseases and conditions: See the current CDT code book for details

Prior review, documentation, and billing guidance for providers

Prior Authorization

Prior Authorization and Documentation Required

Prior review: Requests for implant-supported removable prosthetics require prior review/authorization per the member's plan. Include current full‑mouth radiographic imaging and all supporting documentation with the request. Repair or replacement requests require a detailed narrative and/or chart notes. Benefits and prior review requirements are contract dependent; verify subscriber contract prior to treatment.

Include current full‑mouth radiographs with all requests
Attach detailed narrative/chart notes for repair or replacement
Verify prior authorization requirements against subscriber contract

Documentation Required

Required Clinical Documentation

Documentation: A letter of dental necessity is required when limited retention is cited as the primary justification for implant‑supported removable prosthetic placement. The letter must describe the inability to wear a removable appliance, summarize prior failed corrective procedures, and be supported by appropriate radiographic evidence. Current full‑mouth radiographic imaging is required for all initial requests.

Letter of dental necessity when limited retention is claimed (describe clinical findings and prior failed treatments)
Supporting radiographs (current full‑mouth series or equivalent)
Include history and prior corrective procedure documentation

Billing Rule

Accidental Injury — Medical Plan Referral

Medical plan referral for accidental injury: When replacement of missing teeth is due to an external blow or blunt trauma, refer the claim to the subscriber/employee's medical plan first. Many medical plans cover dental services related to accidental injury; benefits coordination is required before billing the dental plan.

If injury is due to external blow/blunt trauma, submit to medical plan first
Coordinate benefits and include medical plan determination in dental submission

Billing Rule

Temporary/Provisional Prosthetic Billing

Inclusion of temporary prosthetic: A temporary or provisional implant‑supported removable prosthetic is considered inclusive with the final restoration and is not separately billable unless the provider contract explicitly allows separate billing. Verify contract terms prior to billing.

Temporary/provisional prosthesis considered inclusive with final restoration (not separately billable unless contract permits)
Check provider contract for any exceptions

Background and scope

Implant-supported removable prosthetics are prostheses that replace missing teeth and can be removed by the patient. Indications for consideration include replacement of teeth lost from accidental traumatic injury, pathologic disorders resulting in extraction, congenitally missing teeth, or extractions due to congenital tooth disorders. Review for medical/dental necessity requires that the implant body be stable (see dental clinical policy #06-101), and that current full mouth radiographic imaging be provided. When tooth loss is due to an external blow or blunt trauma, claims must first be referred to the subscriber's medical plan because medical coverage may apply. If inability to wear a removable appliance due to limited retention is asserted, a letter of dental necessity, supporting radiographic evidence, and documentation of failed corrective procedures are required. Temporary or provisional implant removable prosthetics are considered inclusive with the final restoration and not separately billable depending on contract.

Key definitions

Removable (definition)

DefinitionRemovable — able to be taken out by the patient; distinguishes patient‑removable prosthetics from implant‑supported retrievable prosthetics that can only be removed by a dentist.

Who determines removabilityDetermination is based on whether the prosthesis can be removed by the patient versus requiring a dentist for removal, per the policy definition.

Implication for reviewRemovability affects benefit review and coverage determinations because implant‑supported removable prosthetics are specifically addressed by this policy.

Generally accepted standards of dental practice

DefinitionGenerally accepted standards of dental practice — standards based on credible scientific evidence published in peer‑reviewed dental literature, specialty society recommendations, views of recognized dentists practicing in the relevant clinical area, and other relevant credible sources.

ApplicationServices must be in accordance with these standards in terms of type, frequency, extent, and effectiveness for the patient’s dental injury or disease.

ExclusionsServices that are primarily for convenience or cosmetic in nature are not considered to meet generally accepted standards for purposes of medical/dental necessity under this policy.