CurrentuniverahealthcarePolicy 13.01.01

Dental Implants

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Criteria and coverage guidance for dental implant placement, including when single implants, implant-supported dentures, and related services are considered medically appropriate or not for Univera Healthcare members.

Policy Summary

Payeruniverahealthcare

PolicyDental Implants

Policy CodePolicy 13.01.01

Change TypeNo material change

Effective DateJul 16, 2026

Last ReviewJul 16, 2026

Next Review DateJul 1, 2027

Key ActionSubmit a predetermination/dental plan with clinical and radiographic details when requesting implant services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4max upper implant bodies

2max lower implant bodies

<4functional deficit threshold

97%5-year survival

Multiple

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CurrentuniverahealthcarePolicy 13.01.01

Dental Implants

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Policy Summary

Payeruniverahealthcare

PolicyDental Implants

Policy CodePolicy 13.01.01

Change TypeNo material change

Effective DateJul 16, 2026

Last ReviewJul 16, 2026

Next Review DateJul 1, 2027

Key ActionSubmit a predetermination/dental plan with clinical and radiographic details when requesting implant services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4max upper implant bodies

2max lower implant bodies

<4functional deficit threshold

97%5-year survival

Multiple

ADA CDT codes listed

Coverage Criteria for Dental Implants

Single implant coverage

Covered when the following condition is met

Functional deficit for single implant: Single dental implants are considered medically appropriate when a functional deficit exists: less than four (4) points of contact for posterior natural or prosthetic teeth, molars, or bicuspids, in occlusion per side.< 4 points of contact per side

From policy statement.

Implant bodies for denture anchoring

Covered when ALL of the following are met

Implant bodies to anchor denture: Dental implant bodies are considered medically appropriate to anchor a denture (not a fixed prosthesis) if traditional dentures dislodge or are painful.N/A

From policy statement.

Quantity limits: Coverage for implant bodies to anchor dentures is limited to four (4) upper implant bodies or two (2) lower implant bodies.Upper ≤4; Lower ≤2

From policy statement.

Covered implant procedures

Covered when procedures are consistent with standard implant placement and associated supported prosthetic/restorative services as listed in CDT code groups

Implant placement and related procedures: Implant surgical placement and associated restorative procedures (as identified by covered CDT codes such as D6010, D6065, D6104, D6110-D6119, and other listed covered codes) are considered under the policy when clinically indicated.

See code lists for specifics

Not covered CDT procedures

Non-covered procedures: Certain procedures are explicitly listed as non-covered (examples include D5725 rebase hybrid prosthesis; D6011 surgical placement of interim implant body; D6040 surgical placement of mini-implant; and placement of transosteal or eposteal implants as described in the code list).

These codes are identified in the 'Non-Covered CDT Codes' section.

Dental implants to replace posterior teeth have specific clinical limits. In particular, implants placed solely to replace a second molar when a functional first molar occlusion exists are considered not medically necessary. Similarly, implants to replace third molars (wisdom teeth) are considered not medically necessary because no functional deficit exists. The policy also excludes implants when the total number of teeth requiring replacement is excessive, when ongoing maintenance is not essential, or when malocclusion is present (upper and lower teeth do not align properly on closure).

The policy lists specific CDT procedure codes that are not covered. Examples include: D5725 (rebase hybrid prosthesis), D6011 (surgical placement of an interim implant body/second‑stage implant surgery), D6040 (surgical placement of a mini‑implant), and codes describing transosteal and eposteal implant placements and certain interim abutment placements. These codes are identified in the "Non‑Covered CDT Codes" section and must not be billed as covered implant placement when the member’s contract does not allow them.

Medicare does not cover routine dental care or items and services related to the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth. This exclusion is described in the Medicare Benefit Policy Manual, Chapter 16, Section 140, and means that Medicare products generally will not reimburse dental implant services unless specific product rules state otherwise.

Reinforcing the exclusion criteria: implants intended only to replace a second molar when the first molar provides functional occlusion, and implants to replace third molars, are considered not medically necessary in routine situations and are likely to be denied. The policy also flags implants as not medically necessary when replacement is excessive, maintenance is not essential, or malocclusion exists.

The policy uses code status labels to indicate clinical or coverage implications: (E/I) denotes procedures considered experimental/investigational, while (NMN) denotes procedures judged not medically necessary. Codes marked with these statuses in the CDT lists should be interpreted according to those designations; procedures with an experimental/investigational status are not considered standard covered services under this policy and may be excluded from reimbursement.

Procedure and Diagnosis Codes

Covered CDT Codes (partial list)CDTCovered

D6010	Surgical placement of implant body: endosteal implant
D6056	Prefabricated abutment - includes modification and placement
D6057	Custom fabricated abutment - includes placement; created by a laboratory process
D6058	Abutment supported porcelain/ceramic crown; a single crown restoration that is retained, supported and stabilized by an abutment on an implant
D6059	Abutment supported porcelain fused to metal crown (high noble metal)
D6060	Abutment supported porcelain fused to metal crown (predominantly base metal)
D6061	Abutment supported porcelain fused to metal crown (noble metal)
D6062	Abutment supported cast metal crown (high noble metal)
D6063	Abutment supported cast metal crown (predominantly base metal)
D6064	Abutment supported cast metal crown (noble metal)

Covered CDT Codes (continued)CDTCovered

D6065	Implant supported porcelain/ceramic crown; A single crown restoration that is retained, supported and stabilized by an implant
D6066	Implant supported crown - porcelain fused to high noble alloys
D6067	Implant supported crown - high noble alloys
D6082	Implant supported crown - porcelain fused to predominantly base alloys
D6083	Implant supported crown - porcelain fused to noble alloys
D6086	Implant supported crown - predominantly base alloys
D6087	Implant supported crown - noble alloys
D6088	Implant supported crown - titanium and titanium alloys
D6092	Re-cement or re-bond implant/abutment supported crown
D6193	Replacement of an implant screw

1–10 of 13

1/2

Non-Covered CDT Codes (partial list)CDTNot Covered

D5725	Rebase hybrid prosthesis
D6011	Surgical placement of interim implant body for transitional prosthesis (second stage surgery)
D6040	Surgical placement of mini-implant
D6068	Placement of interim abutment; a healing cap is not an interim abutment

Additional CDT Codes (maintenance, grafting, prostheses)CDTCovered

D6081	Scaling and debridement of a single implant in the presence of mucositis (without flap entry and closure)
D6085	Interim implant crown
D6090	Repair of implant/abutment supported prosthesis
D6091	Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis
D6093	Re-cement or re-bond implant/abutment supported fixed partial denture
D6098	Implant supported retainer - porcelain fused to predominantly base alloys
D6099	Implant supported retainer for FPD - porcelain fused to noble alloys
D6101	Debridement of a peri-implant defect including surface cleaning with flap entry and closure
D6102	Debridement and osseous contouring of a peri-implant defect including surface cleaning
D6104	Bone graft at time of implant placement

1–10 of 12

1/2

Prosthesis and related CDT CodesCDTCovered

D6112	Implant/abutment supported removable denture for partially edentulous arch
D6113	Implant/abutment supported removable denture for maxillary partially edentulous arch
D6114	Implant/abutment supported fixed denture for edentulous arch - maxillary
D6115	Implant/abutment supported fixed denture for edentulous arch - mandibular
D6116	Implant/abutment supported fixed denture for partially edentulous arch - maxillary
D6117	Implant/abutment supported fixed denture for partially edentulous arch - mandibular
D6118	Implant/abutment supported interim fixed denture for edentulous arch - mandibular
D6119	Implant/abutment supported interim fixed denture for edentulous arch - maxillary
D6120	Implant supported retainer - porcelain fused to titanium and titanium alloys
D6191	Radiographic/surgical implant index, by report

1–10 of 12

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Maintenance and interim CDT CodesCDTCovered

D6198	Remove interim implant component
D6280	Implant maintenance procedures when a full arch removable implant/abutment supported denture is removed and reinserted (per arch) (Effective 01/01/26)
D6793	Interim retainer crown - further treatment or completion of diagnosis necessary prior to final impression

Diagnosis codingICD-10

ICD-10 Not Applicable

ICD-10 diagnosis codes are not required for billing of dental services under a member's dental contract

Example CDT Procedure Codes referencedmixed

D6195	Abutment supported retainer - porcelain fused to titanium and titanium alloys; a metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability from abutment
D6198	Remove interim implant component; removal of implant component (e.g., interim abutment; provisional implant crown) originally placed for a specific clinical purpose and period of time determined by the dentist
D6280	Implant maintenance procedures when a full arch removable implant/abutment supported denture is removed and reinserted, including cleansing of prosthesis and abutments - per arch (Effective 01/01/26)
D6793	Interim retainer crown - further treatment or completion of diagnosis necessary prior to final impression; not to be used as a temporary retainer crown for a routine prosthetic restoration

Diagnosis codesICD-10

ICD-10

Not Applicable - ICD-10 diagnosis codes are not required for billing dental services processed under a member's dental contract

Buccal bony defect size (trial inclusion)

Buccal bony defect size (trial inclusion)>= 5 mm

Provider Actions, Prior Authorization, and Billing Guidance

Prior Authorization

Predetermination recommended — submit dental plan with clinical and radiographic details

A predetermination of benefits for implant services is recommended. Submit a dental plan to the Health Plan for consideration that includes the number and location of the missing teeth, the interarch distance, the number, type and location of the implants to be placed, the existing and proposed occlusal scheme, the design and type of the planned restoration, and complete or panoramic radiographic imaging (including bitewings for posterior teeth) current to within the past year showing the condition of the dentition.

Number and location of missing teeth
Interarch distance
Number, type and location of implants
Existing and proposed occlusal scheme
Design and type of planned restoration
Complete or panoramic radiographic imaging, including bitewings (current to past year)

Prior Authorization

Prior authorization / coverage verification recommended for listed CDT codes

Background and Rationale

Dental implants are artificial tooth roots surgically placed into the mandible or maxilla to support restorations such as single crowns, fixed bridges, or removable prostheses. They can replace one or multiple missing teeth, anchor dentures when traditional prostheses are inadequate, and may be placed immediately at extraction or in staged procedures. Risk factors that affect implant outcomes and peri‑implant disease include prior periodontal disease, smoking, poor plaque control, diabetes, and other patient‑specific considerations.

Definitions

Endosteal (endosseous) implant — definition

Endosteal (endosseous) implantA device placed into the alveolar and basal bone of the mandible or maxilla transecting only one cortical plate.

Abutment / custom abutment — definition

AbutmentA manufactured connection to an implant, usually made of machined high noble metal, titanium, titanium alloy, or ceramic.

Custom abutmentA fabricated abutment created for a specific patient using a casting process, typically of titanium, zirconia/ceramic, or noble/high noble metal.

Peri-implant disease — definition

Peri-implant diseaseInflammatory conditions affecting tissues around dental implants analogous to periodontal disease in natural teeth; risk factors include history of periodontal disease, smoking, poor plaque control, diabetes, and individual patient considerations.

Policy Summary

Payeruniverahealthcare

PolicyDental Implants

Policy CodePolicy 13.01.01

Change TypeNo material change

Effective DateJul 16, 2026

Last ReviewJul 16, 2026

Next Review DateJul 1, 2027

Key ActionSubmit a predetermination/dental plan with clinical and radiographic details when requesting implant services.

SourceLink

On This Page

Some CDT procedure codes listed in the policy (D6010–D6199 and other groups) may require prior authorization or may not be covered under all circumstances; providers should verify coverage or prior authorization requirements with the member's benefit plan.

Verify coverage for codes in the covered CDT lists (e.g., D6010, D6065, D6110–D6119)
Confirm prior authorization requirements for procedures that may be product- or contract-dependent

Prior Authorization

Product-dependent prior authorization and coverage — verify per product rules

Coverage and the need for prior authorization depend on the member's product: if a commercial, Medicaid (where no state guidelines exist), or Medicare product covers a service, the medical policy criteria apply; coverage and authorization requirements vary by product and benefit design.

Determine whether the member's product covers the service — medical policy criteria apply only when the product provides coverage
Follow product-specific prior authorization rules (commercial, Medicaid, Medicare) as applicable

Billing Rule

Included components and bundled services — implant, abutment, crown and perioperative care

When policy criteria are met, coverage is provided for the implant, abutment, and crown (fixed or removable). Anesthesia and routine pre- and post-operative procedures, impressions, sutures, and suture removal are included in the allowable expense for the implant surgical procedure; no additional benefits for these services will be provided.

Implant, abutment, and crown are included when criteria met
Anesthesia and routine perioperative care are bundled into the implant surgical allowance

Denial Risk

Non-covered procedure considerations — listed CDT codes must not be billed as covered

Certain procedures are specifically identified as non-covered CDT codes (examples include rebase hybrid prosthesis, surgical placement of interim implant body, surgical placement of mini-implant, transosteal and eposteal implants, and placement of interim abutment); these must not be billed as covered implant placement.

Examples of non-covered codes: D5725, D6011, D6040, transosteal and eposteal implant procedures, placement of interim abutment

Documentation Required

Predetermination documentation required — include specified clinical, restorative and radiographic details

A predetermination/dental plan should include specific documentation elements: number and location of missing teeth, interarch distance, number/type/location of implants, existing and proposed occlusal scheme, planned restoration design/type, and complete or panoramic radiographic imaging (including bitewings for posterior teeth) current to within the past year.

Number and location of missing teeth
Interarch distance
Number, type and location of implants
Existing and proposed occlusal scheme
Design and type of planned restoration
Complete or panoramic radiographs including bitewings (current to past year)

Billing Rule

Diagnosis coding for dental claims — ICD-10 not required under dental contracts

ICD-10 diagnosis codes are not required for billing dental services processed under a member's dental contract; the policy states ICD-10 codes are 'Not Applicable' for these dental claims.

Do not include ICD-10 codes when billing services under a member's dental contract unless otherwise required by the product

Note

ICD-10 not required for dental contract billing

Clarification: ICD-10 diagnosis codes are not required when billing dental services processed under a member's dental contract (policy lists ICD-10 as 'Not Applicable').

Billing under a dental contract does not require ICD-10 codes per the policy

Denial Risk

Situations likely to be denied — second/third molar and excessive or nonessential replacements

Claims are likely to be denied for implants to replace second molars when a functional first molar occlusion exists, for implants to replace third molars (no functional deficit), and when implant replacement is excessive, maintenance is not essential, or malocclusion is present.

Second molar replacement when first molar occlusion is functional
Third molar (wisdom tooth) replacements
Situations where replacement is excessive, maintenance not essential, or malocclusion exists

Denial Risk

Coverage conditionality — absence of coverage or unmet requirements can cause denials

Codes and services in this policy may not be covered under all circumstances; if requirements or product coverage are not met, the absence of coverage may result in claim denial.

Verify that policy criteria and product benefits are met before billing
Lack of coverage or unmet requirements can lead to denial

Prior Authorization

Contract coverage dependency — verify product benefits before applying policy

Services are contract dependent; if a product does not cover a specific service, the medical policy criteria do not apply and lack of product coverage can trigger claim denial.

Confirm the member's product covers the service before applying medical policy criteria
If the product does not cover the service, do not bill under this policy expectation

Regulatory status — FDA/regulatory note

Regulatory status (U.S.)Dental implants and related components are regulated medical devices; all dental implants and related components require FDA approval before marketing and use in the United States.

Examples of CDT codes and brief descriptions

D6195Abutment supported retainer - porcelain fused to titanium and titanium alloys; metal-ceramic retainer for a fixed partial denture.

D6198Remove interim implant component; removal of implant component originally placed for a specific clinical purpose and period of time determined by the dentist.

D6280Implant maintenance procedures when a full arch removable implant/abutment supported denture is removed and reinserted, including cleansing of prosthesis and abutments - per arch (Effective 01/01/26).

D6793Interim retainer crown - further treatment or completion of diagnosis necessary prior to final impression; not to be used as a temporary retainer crown for a routine prosthetic restoration.