CurrentEmpire BluecrossPolicy 06-101

Surgical Placement of Implant Body

Clinical guidance for evaluation and surgical placement of dental implant bodies (endosteal, subperiosteal, transosteal, zygomatic, craniofacial, mini) and related procedures; intended for dental providers and utilization reviewers determining medical/dental necessity and contract applicability.

Policy Summary

PayerEmpire Bluecross

PolicySurgical Placement of Implant Body

Policy CodePolicy 06-101

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProvide comprehensive treatment plan and current (within 12 months) pretreatment radiographic images when submitting for review or authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D6010-D6198CDT procedure codes listed

Images ≤12 moRadiographic requirement

01/01/2024Last review

NCApplicable state

Coverage Criteria

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Clinical indication: To replace missing natural teeth due to accidental traumatic injuries, extensive structural damage, pathological disorders, or congenital/developmental anomalies.

Standard of care: Treatment must be in accordance with generally accepted standards of dental practice (credible peer‑reviewed evidence, specialty society recommendations, and the views of recognized practitioners).

Alternative services: Replacement of multiple teeth by implants in the same arch is not appropriate when less costly dental services can adequately restore occlusion and function (group contract dependent).

Imaging: Current (within 12 months), dated diagnostic pretreatment radiographic images (full mouth series, panoramic, and/or other appropriate radiographic images) must be provided.within 12 months

Periodontal documentation: Comprehensive treatment plan may be requested including periodontal status and documentation of a history of definitive periodontal treatment and maintenance for the remaining teeth.

Allergy documentation: Patient sensitivity (allergy) to denture restorative materials may qualify for implant placement; requires physician and dental provider letters of medical/dental necessity and a copy of laboratory analysis of the allergy.

Inability to wear removable appliance: 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 a history of failed corrective procedures.

Immediate placement of an implant in an extraction site is an acceptable procedure.

Benefits for implant placement are not considered for correction of developmental or congenital defects unless the member's group contract specifically provides coverage. The policy explicitly notes that replacement of multiple teeth by implants in the same arch may also be limited when less costly alternatives can adequately restore occlusion and function; applicability depends on the group contract.

Services that do not meet generally accepted standards of dental practice or that are performed primarily for cosmetic reasons may be considered not medically necessary or nonpayable under the dental plan. "Generally accepted standards of dental practice" are defined as standards based on credible peer‑reviewed dental literature, specialty society recommendations, and the views of recognized practitioners, and care must be effective, not primarily for convenience, and not more costly than appropriate alternatives.

Because coverage is contract dependent, a determination that a procedure is clinically appropriate does not guarantee it is a covered benefit payable by the plan; services that fail to meet the plan's standards or that are excluded by the member's contract may be denied.

Coding

Procedure codes listedCDT (as presented)

D6010	Surgical placement of implant body (fixture): endosteal implant
D6011	Second stage implant surgery
D6012	Surgical placement of interim implant body (fixture) for transitional prosthesis: endosteal implant
D6013	Surgical placement of mini implant
D6040	Surgical placement: eposteal implant
D6050	Surgical placement: transosteal implant
D6100	Surgical removal of implant body
D6198	Remove interim implant component (e.g., interim abutment; provisional implant crown)
D7993	Surgical placement of craniofacial implant extra oral
D7994	Surgical placement: zygomatic implant

Diagnosis codes (referenced)ICD-10

ICD-10

ICD-10 CM Diagnoses for Dental Diseases and Conditions: see the current CDT code book for details

Provider Actions and Requirements

Prior Authorization

Prior Authorization / Plan Review May Be Required

Prior authorization or plan review may be required for surgical placement of an implant body depending on the member's contract and line of business. Contact the customer service number on the member's ID card to determine if review is required prior to scheduling.

Plan review may be triggered by contract requirements that benefits meet generally accepted standards of dental care at the lowest cost that properly addresses the patient’s condition.

Denial Risk

Services that do not meet generally accepted standards of dental care or are not payable under the member’s contract may be denied. A determination that a service is medically or dentally necessary does not guarantee it is a covered benefit under the dental plan.

Denial may occur when documentation or clinical indications do not support medical/dental necessity or when the service is excluded by contract.

Documentation Required

Documentation Requirements — Comprehensive Treatment Plan & Periodontal Status

A comprehensive treatment plan may be requested and should include the patient’s periodontal status and documentation of definitive periodontal treatment and maintenance for remaining teeth when applicable. Provide current (within 12 months), dated, diagnostic pretreatment radiographic images (full‑mouth series, panoramic, and/or other appropriate images).

Comprehensive treatment plan including periodontal status and history of definitive periodontal treatment and maintenance for remaining teeth (when applicable).
Current (≤ 12 months) dated diagnostic pretreatment radiographs: full‑mouth series, panoramic, and/or other appropriate images.

Note

Provider Actions — Submission and Supporting Documentation

Provider actions should include submitting letters of medical/dental necessity and supporting documentation for qualifying conditions. Examples: documented allergy to denture restorative materials (physician and dental letters plus laboratory allergy analysis) or inability to wear a removable appliance due to limited retention (letter of dental necessity, radiographic evidence, and history of failed corrective procedures).

If patient sensitivity (allergy) to denture materials is claimed, include physician and dental provider letters and laboratory analysis of the allergy.
If inability to wear a removable appliance is claimed, include a letter of dental necessity, supporting radiographs, and documentation of failed corrective procedures.

Background

Dental implants are used to replace missing natural teeth resulting from accidental trauma, extensive structural damage, pathological disorders, or congenital/developmental anomalies. Implant placement is evaluated against generally accepted standards of dental practice and should be effective for the patient's condition, not primarily cosmetic, and considered in light of lower‑cost alternatives that adequately restore occlusion and function.

Clinical documentation requirements commonly requested for review include a comprehensive treatment plan with periodontal status and history of definitive periodontal treatment and maintenance for remaining teeth; current (within 12 months) dated diagnostic pretreatment radiographic images (full mouth series, panoramic, and/or other appropriate images); and supporting letters of medical/dental necessity or laboratory analysis for documented material allergy when applicable.

Immediate placement of an implant into an extraction site is acknowledged as an acceptable procedure when clinically appropriate. Final coverage and medical necessity determinations remain subject to the member's contract terms and local plan implementation.

Definitions

Generally accepted standards of dental practice — definition/criteria

DefinitionStandards based on credible peer-reviewed dental literature, specialty society recommendations, views of recognized dentists practicing in the relevant clinical area, and other credible sources.

ScopeCare that a dentist, exercising prudent clinical judgment, provides to evaluate, diagnose, or treat a dental injury or disease and that is in accordance with generally accepted standards of dental practice (type, frequency, extent, and effectiveness).

ExclusionsServices that are primarily for convenience or cosmetic purposes, or are more costly than an effective alternative service, are not considered within generally accepted standards of dental practice.

Operational noteDetermination requires credible scientific evidence, specialty society recommendations, and consensus views of recognized practitioners in the clinical area.

Candidates for implant placement — patient selection criteria

IndicationsPatients with tooth loss due to accidental traumatic injuries, extensive structural damage, pathological disorders, or congenital/developmental anomalies.

Multiple-teeth limitationReplacement of multiple teeth by implants in the same arch is not appropriate when less costly dental services can adequately restore occlusion and function (group contract dependent).

Assessment requirementCandidate selection should be guided by generally accepted standards of dental practice and prudent clinical judgment of the treating dentist.

Documentation considerationsCandidates should have clinical justification documented in the treatment plan and supporting records per policy requirements.