CurrentUnitedHealthcarePolicy DCPO35.10

Space Maintainers (dental)

This UnitedHealthcare Dental Clinical Policy addresses indications, contraindications, and coding for space maintainers used to preserve arch space after premature loss of primary teeth. It is intended to assist interpretation of standard and Medicare Advantage dental plans but benefit coverage is governed by member-specific plan documents.

Policy Summary

PayerUnitedHealthcare

PolicySpace Maintainers (dental)

Policy CodePolicy DCPO35.10

Change TypeTemplate update; classification changed to Clinical Policy

Effective DateJun 1, 2025

Next Review Date

Key ActionProvider must document premature loss of primary tooth/teeth and clinical rationale that space maintenance is required and document absence of contraindications when submitting for coverage.

POLICY UPDATE CHANGES

Template Update changed policy type classification from 'Coverage Guideline' to 'Clinical Policy'.

1Covered Indication Type (space maintenance after premature primary tooth loss)

4Contraindication Criteria Listed

14CDT Codes Listed

Coverage Summary

This UnitedHealthcare Dental Clinical Policy addresses indications, contraindications, and coding for space maintainers used to preserve arch space after premature loss of primary teeth. It is intended to assist interpretation of standard and Medicare Advantage dental plans but benefit coverage is governed by member-specific plan documents.

Space maintainers are passive appliances designed to prevent tooth movement following premature loss of primary teeth so permanent teeth can erupt into proper position. The goal of space maintenance is to preserve arch length, width, and perimeter by maintaining the relative position of the existing dentition.

Medical-Necessity Criteria

Indications (Medically Necessary)

Space Maintainers are indicated when ALL of the following are met:

ALL of the following

Premature loss of a primary tooth/teeth
Need to maintain space so permanent teeth can erupt into proper position
Goal to prevent loss of arch length, width, and perimeter by maintaining relative position of existing dentition

Premature loss of a primary tooth/teeth

Need to maintain space so permanent teeth can erupt into proper position

Goal to prevent loss of arch length, width, and perimeter by maintaining relative position of existing dentition

Contraindications (Not Indicated)

Space Maintainers are contraindicated when ANY of the following are present:

Member is not compliant or has poor oral hygiene
Permanent tooth/teeth is/are close to eruption
Severe crowding already exists
Space has already been lost

Member is not compliant or has poor oral hygiene

Permanent tooth/teeth is/are close to eruption

Applicable CDT Procedure Codes

Applicable CDT Procedure Codes (reference list)mixed

D1510	Space maintainer fixed unilateral per quadrant
D1516	Space maintainer fixed bilateral, maxillary
D1517	Space maintainer fixed bilateral, mandibular
D1520	Space maintainer removable unilateral per quadrant
D1526	Space maintainer removable bilateral, maxillary
D1527	Space maintainer removable bilateral, mandibular
D1551	Re-cement or re-bond bilateral space maintainer maxillary
D1552	Re-cement or re-bond bilateral space maintainer mandibular
D1553	Re-cement or re-bond unilateral space maintainer per quadrant
D1556	Removal of fixed unilateral space maintainer per quadrant

1–10 of 14

1/2

Listing of a code does not guarantee coverage — benefit determination is governed by the member-specific benefit plan document and applicable laws; the inclusion of a code does not imply any right to reimbursement or guarantee claim payment.

Provider Actions & Documentation Requirements

Documentation Required

Document indication for space maintainer

Provider must document premature loss of primary tooth/teeth and clinical rationale that space maintenance is required to allow proper eruption of permanent teeth and to preserve arch dimensions.

D1510
D1516
D1517
D1520
D1526
D1527
D1575

Documentation Required

Document contra-indications

Provider must document absence of contraindications (e.g., poor oral hygiene/noncompliance, permanent tooth near eruption, severe crowding, or already lost space) when submitting for coverage.

Member is not compliant or has poor oral hygiene
Permanent tooth/teeth is/are close to eruption
Severe crowding already exists
Space has already been lost

Billing Rule

Use CDT codes from policy

Report the appropriate CDT procedure code from the provided list; listing of a code does not guarantee coverage—benefit determination governed by member-specific plan.

D1510
D1516
D1517
D1520
D1526
D1527
D1551
D1552
D1553
D1556
D1557
D1558
D1575
D1999

Definitions & Supporting Evidence

Space Maintainer: A passive appliance, usually cemented in place, that holds teeth in position (ADA).

References: AA Pediatric Dentistry guideline (2008-2009), Gen Dent (2015), ADA CDT 2025 and other dental texts referenced.