CurrentSelectHealthPolicy DOO5

Fixed partial denture (FPD) reimbursement / billing policy

SelectHealth policy DOO5 defines reimbursement and billing/coding guidance for fixed partial denture (FPD) procedures for Commercial and Select Health Advantage (Medicare/CMS) plans, including clinical documentation requirements and an extensive list of CDT procedure codes. It notes review for cosmetic procedures on anterior teeth and requires pre-op x-rays and narrative for review.

Policy Summary

PayerSelectHealth

PolicyFixed partial denture (FPD) reimbursement / billing policy

Policy CodePolicy DOO5

Change TypeRevisions listed (no material change)

Effective DateJan 1, 2009

Next Review Date

Key ActionSubmit chart notes when FPDs attach to natural teeth and pre-operative X-rays plus a narrative for anterior teeth; ensure implants are approved for coverage before billing.

SourceLink

POLICY UPDATE CHANGES

Revision history includes dates 05/27/14, 01/28/16, 02/23/17, 10/19/2022.

~45CDT codes listed

1Primary coverage criteria group

1Pre-op imaging required (anterior)

Policy summary

Policy DOO5 — Fixed Partial Denture (FPD): This SelectHealth reimbursement policy covers Fixed Partial Dentures (FPD), defined as a one-piece prosthesis made to fill an edentulous space and anchored by crowns on either side; it may include crowns and pontics attached to natural teeth or implants. Purpose: provides reimbursement and billing/coding guidance for FPD procedures when clinical necessity and required documentation are met.

Key requirements: Reimbursement is contingent on documentation of clinical necessity — for FPDs attached to natural teeth, chart notes must indicate why the tooth was removed (examples: prior restorations, root canal, or infection); FPDs attached to implants are reimbursed only when the implants have been approved for coverage. Services on anterior teeth will be reviewed for cosmetic intent and require pre-operative X-rays and a narrative for review.

Coverage criteria

Commercial Plan Coverage Criteria

Select Health will reimburse fixed partial denture procedures when the following criteria are met:

ALL of the following

If attached to natural teeth
- Chart notes submitted should indicate that it was necessary to remove the tooth (e.g: previous restorations, root canal, or infection)
Fixed partial denture are attached to implants that have been approved for coverage
Anterior tooth cosmetic review: Services on anterior teeth will be reviewed to determine if procedures were performed for cosmetic purposes; pre-operative X-rays and a narrative are required for review
If cosmetic intent suspected, provide pre-op X-rays and narrative

Select Health Advantage (Medicare/CMS)

Medicare plan follows the commercial plan

Coverage and review follows the Commercial Plan Coverage Criteria

CDT codes (billing reference)

Covered / Billable CDT Codes for Fixed Partial Dentures and Related Retainers/Pontics/Crowns (listed for informational billing use)mixed

D6205	Pontic- indirect resin-based composite
D6068	Abutment supported retainer for porcelain/ceramic FPD
D6069	Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
D6070	Abutment supported retainer for porcelain fused to metal FPD (predominantly base metals)
D6071	Abutment supported retainer for porcelain fused to metal FPD (noble metal)
D6195	Abutment supported retainer porcelain fused to titanium and titanium alloys
D6072	Abutment supported retainer for cast metal FPD (high noble metal)
D6073	Abutment supported retainer for cast metal FPD (predominantly base metal)
D6074	Abutment supported retainer for cast metal FPD (noble metal)
D6194	Abutment supported retainer crown for FPD titanium and titanium alloys

1–10 of 50

1/5

Actions required of providers

Documentation Required

Documentation for FPD attached to natural teeth

Submit chart notes showing it was necessary to remove the tooth when the fixed partial denture is attached to natural teeth.

Previous restorations
Root canal
Infection

Documentation Required

Pre-operative documentation for anterior teeth

When procedures involve anterior teeth, provide pre-operative X-rays and a narrative so the services can be reviewed for possible cosmetic intent.

Billing Rule

Implant attachment coverage requirement

Fixed partial dentures attached to implants are reimbursed only when the implants have been approved for coverage.

Note

Follow commercial criteria for Medicare Advantage

Select Health Advantage follows the Commercial Plan coverage criteria for reimbursement and documentation requirements.

Policy revision timeline

05/27/14revised

Revision history includes date 05/27/14; source shows revision dates but does not specify clinical policy statement changes.

01/28/16revised

Revision history includes date 01/28/16; source shows revision dates but does not specify clinical policy statement changes.

02/23/17revised

Revision history includes date 02/23/17; source shows revision dates but does not specify clinical policy statement changes.

10/19/2022revisedLatest

Revision history includes date 10/19/2022; source shows revision dates but does not specify clinical policy statement changes.