CurrentUnitedHealthcarePolicy DCP007.14

Dental Implant Placement and Treatment of Peri-Implant Defects/Disease

This policy governs placement of dental implants and clinical management of peri-implant mucositis and peri-implantitis for UnitedHealthcare dental plans; it applies to providers delivering implant-related surgical and peri-implant services for members subject to their benefit plan documents.

Policy Summary

PayerUnitedHealthcare

PolicyDental Implant Placement and Treatment of Peri-Implant Defects/Disease

Policy CodePolicy DCP007.14

Change TypeCode removaladministrative update

Effective DateJun 1, 2025

Next Review Date

Key ActionDocument implant type, surgical details, osseointegration status, infection status, and risk factors when submitting for coverage.

SourceLink

POLICY UPDATE CHANGES

Removed CDT code D6080 from Applicable Codes.

Changed policy type classification from 'Coverage Guideline' to 'Clinical Policy'.

Effective date updated to June 1, 2025 for the current policy version.

~20CDT procedure codes listed

1.5-2 mmminimum required distance from adjacent tooth roots

06/01/2025policy effective date

DCP007.14policy identifier

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Coverage Criteria and Considerations

Coverage criteria and considerations

Covered when ALL clinical placement and site-selection criteria are met; consider individual and lifestyle risk factors when planning treatment.

Placement Guidelines: Implant may be placed at time of extraction; implant site must be free of infection; implant must be a minimum of 1.5-2 mm from adjacent tooth roots.

From Guidelines for Dental Implant placement

Patient factors to consider: Patient must be willing/able to participate in oral hygiene and routine dental care; consider occlusal load, bone quality/quantity, history of or active periodontal disease, adequate restorative space, and patient age.

List of individual clinical factors

Conditions that may interfere with healing: Conditions/treatments that may interfere with normal healing (e.g., chemotherapy, radiation to head and neck, uncontrolled diabetes or hypertension, recent myocardial infarction or stroke, anticoagulant therapy, blood dyscrasias, IV bisphosphonate therapy, estrogen deficiency, significant psychiatric disorder, intellectual disability).

Clinical contraindications or risk modifiers

Lifestyle risk factors: Smoking, drug addiction, or alcoholism are listed as risk factors to consider in treatment planning.

Lifestyle considerations

Peri-implant disease treatment indication: Treatment of peri-implant defects/disease (including non-surgical and surgical therapies) is indicated for peri-implant mucositis and peri-implantitis, provided the implant is not mobile.

Treatment not indicated if implant is mobile

Treatment of peri-implant defects or peri-implant disease is not indicated if the implant is mobile.

The listing of CDT and other procedure codes is provided for reference only and does not imply that the service described by a code is a covered or noncovered health service; actual coverage and any prior authorization requirements depend on the member’s specific benefit plan document and applicable laws.

Applicable Procedure Codes

Applicable CDT Procedure Codesmixed

D6010	Surgical placement of implant body: endosteal implant.
D6011	Surgical access to an implant body (second stage implant surgery).
D6012	Surgical placement of interim implant body for transitional prosthesis: endosteal implant.
D6013	Surgical placement of mini-implant.
D6040	Surgical placement: eposteal implant.
D6050	Surgical placement: transosteal implant.
D6051	Placement of interim implant abutment.
D6081	Scaling and debridement of a single implant in the presence of mucositis, including inflammation, bleeding upon probing and increased pocket depths; includes cleaning of the implant surfaces, without flap entry and closure.
D6089	Accessing and retorquing loose implant screw - per screw.
D6100	Surgical Removal of implant body.

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Provider Actions, Documentation, and Authorization

Prior Authorization

Prior Authorization and Coding

Applicable CDT procedure codes are provided for reference only. Coverage and any prior authorization requirements follow member-specific benefit documents; verify eligibility and obtain prior authorization when required before scheduling procedures.

Verify member benefits and obtain prior authorization when required.
Applicable CDT codes listed for reference; coding alone does not guarantee coverage.

Documentation Required

Pain Management Consideration

Encourage nonpharmacological pain management strategies when appropriate (for example: behavioral techniques, cold/heat therapy, topical agents, and other non-opioid modalities). Document pain management counseling in the medical record per CA AB2585 and institutional protocols.

Document patient education and nonpharmacologic interventions offered.
Consider multimodal, non-opioid approaches whenever clinically appropriate.

Documentation Required

Clinical Background

Dental implants are titanium prostheses placed into the maxillary or mandibular bone and restored after osseointegration to replace lost tooth roots. Peri-implant diseases include peri-implant mucositis (inflammation confined to the soft tissues around an implant) and peri-implantitis (soft tissue inflammation with loss of supporting bone). Patient risk factors that influence planning and outcomes include history of periodontal disease, smoking, poor plaque control, diabetes, and other conditions that impair healing.

Key Definitions

Dental Implant (ADA)

DefinitionA device specially designed to be placed surgically within or on the mandibular or maxillary bone as a means of providing for a dental replacement prosthesis (ADA).

Typical materialTitanium or titanium alloy prosthesis used to replace tooth roots and support restorations.

Placement contextPlaced surgically within or on mandibular or maxillary bone and restored after osseointegration.

Peri-Implant Mucositis (AAP)

DefinitionInflammation found only around the soft tissues surrounding a dental implant (Peri-Implant Mucositis, AAP).

Clinical scopeAffects only peri-implant soft tissues without supporting bone loss.

Treatment implicationIndication for peri-implant mucositis treatment; implant mobility would contraindicate certain peri-implant procedures.

Peri-Implantitis (AAP)

DefinitionInflammation around peri-implant soft tissue with deterioration of the bone supporting the dental implant (Peri-Implantitis, AAP).

Clinical scopeIncludes both soft tissue inflammation and supporting bone loss around the implant.

Treatment implicationClassified as peri-implant disease and may indicate need for peri-implant defect treatment unless implant is mobile.