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    v1.0.30
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialWellpoint Implant Prosthetics Coverage | OpenPayer
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    CurrentWellpointPolicy 06-104

    Implant/Abutment Supported Removable Prosthetics Guidelines

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    This dental clinical policy governs coverage consideration and clinical criteria for removable prosthetics supported by dental implants or abutments, including replacement of missing teeth. Final coverage depends on the member’s plan benefits and contract.

    Policy Summary
    PayerWellpoint
    PolicyImplant/Abutment Supported Removable Prosthetics Guidelines
    Policy CodePolicy 06-104
    Change TypeMinor editorial revision
    Effective Date01/01/2025
    Last ReviewOct 29, 2024
    Next Review DateN/A
    Key ActionObtain current, dated pretreatment full-mouth radiographic imaging taken within 12 months of treatment.
    SourceLink
    POLICY UPDATE CHANGES

    The policy was revised with minor editorial refinements to the description, clinical indications, criteria, and references.

    4Clinical indication categories supporting consideration
    12 monthsMaximum age of diagnostic pretreatment radiographs
    6Listed CDT procedure codes
    Not coveredReplacement for aesthetic reasons

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Medical plan firstTrauma claim referral

    Coverage Criteria

    Clinical indications

    Implant/abutment-supported removable prosthetics to replace missing teeth may be considered appropriate when the missing teeth result from any of the following conditions.

    Qualifying clinical indication

    • Traumatic injury: Accidental traumatic injuries to sound, natural teeth resulting in extraction or avulsion.
    • Pathologic disorder: A pathologic disorder resulting in extraction.
    • Congenitally missing teeth.
    • Congenital dental disorder: A congenital disorder of the teeth resulting in extraction.

    General policy and contract criteria

    The following policy and contract-dependent criteria apply to treatment consideration.

    General criteria

    • Diagnostic imaging: Current, dated, diagnostic pretreatment full-mouth radiographic imaging is required.Within 12 months
    • Implant stability: The implant body must be stable.

      See dental clinical policy 06-101.

    • Trauma coordination: When missing teeth resulted from an external blow or blunt trauma, the claim must first be referred to the subscriber's or employee's medical plan.

      The medical plan may cover replacement of missing teeth due to accidental injury.

    Replacement of implant/abutment-supported removable prosthetics for aesthetic reasons is not a covered benefit. Coverage consideration must be based on applicable clinical indications and the member’s contract benefits.

    For plans containing a missing-tooth clause, there is no benefit for replacing missing teeth when an implant/abutment-supported removable prosthetic is treatment planned. For plans without a missing-tooth clause, coverage depends on determination of necessity and any contract-dependent alternate benefit provisions; an alternate benefit may apply to replace all missing teeth where available.

    Temporary or provisional implant/abutment-supported removable prosthetics are considered inclusive with the final restoration and are not separately covered.

    Coding and Documentation Requirements

    CDT Codes Applicable to This DocumentCDT
    D6055Connecting bar - implant supported or abutment supported.
    D6110Implant/abutment supported removable denture for edentulous arch - maxillary.
    D6111Implant/abutment supported removable denture for edentulous arch - mandibular.
    D6112Implant/abutment supported removable denture for partially edentulous arch - maxillary.
    D6113Implant/abutment supported removable denture for partially edentulous arch - mandibular.
    D6090Repair implant supported prosthesis, by report
    Pretreatment full-mouth radiographic imaging
    Imaging typeDiagnostic pretreatment full-mouth radiographic imaging
    Required statusCurrent and dated imaging is required
    Maximum ageWithin 12 months

    Provider Actions and Coverage Risks

    Documentation Required

    Pretreatment Radiographs Required

    Obtain current, dated, diagnostic pretreatment full-mouth radiographic imaging before treatment. The imaging must be obtained within 12 months of treatment.

    Documentation Required

    Repair or Replacement Records

    For repair or replacement of implant/abutment supported removable prosthetics, submit a detailed narrative and/or chart notes when required by the provider contract.

    Denial Risk

    No Benefit Without Completed Delivery

    If the subscriber does not return for delivery, there is no benefit because the service is considered incomplete.

    Clinical Background

    An implant/abutment-supported removable prosthetic can be taken out by the patient. This differs from an implant/abutment-supported fixed denture or hybrid prosthesis, which may be removed only by a dentist. The policy addresses removable prosthetics used to replace missing teeth resulting from traumatic injury, pathologic disorders, congenital absence, or congenital dental disorders.

    Definitions

    Removable implant/abutment-supported prosthetic
    Restoration typeRemovable implant/abutment-supported prosthetic
    DefinitionA prosthetic restoration that can be taken out by the patient
    Removal methodThe patient can remove the prosthetic restoration
    Implant/abutment-supported fixed denture/hybrid prosthesis
    Prosthesis typeImplant/abutment-supported fixed denture/hybrid prosthesis
    DefinitionAn implant/abutment-supported denture or hybrid prosthesis that may only be taken out by a dentist
    Removal method
    Policy Summary
    PayerWellpoint
    PolicyImplant/Abutment Supported Removable Prosthetics Guidelines
    Policy CodePolicy 06-104
    Change TypeMinor editorial revision
    Effective Date01/01/2025
    Last ReviewOct 29, 2024
    Next Review DateN/A
    Key ActionObtain current, dated pretreatment full-mouth radiographic imaging taken within 12 months of treatment.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Documentation RequirementsProvider Actions and Coverage RisksClinical BackgroundDefinitions
    Delivery date: Depending on the provider contract, the delivery date of the implant/abutment-supported removable prosthetic is considered the date of delivery.
  1. Temporary or provisional restoration: A temporary or provisional implant/abutment-supported removable prosthetic is inclusive with the final restoration.
  2. Repair or replacement documentation: Repair or replacement requires a detailed narrative and/or chart notes when required by the contract.

  3. Missing-tooth clause pathway

    • Plan with missing-tooth clause: When the plan contains a missing-tooth clause, there is no benefit for replacement of missing teeth when implant/abutment-supported removable prosthetics is treatment planned.
    • Plan without missing-tooth clause: When the plan does not contain a missing-tooth clause, determine the necessity of the implant-supported removable prosthetic or whether a contract-dependent alternate benefit applies; where alternate benefits exist, an alternate benefit may be applied to replace all missing teeth.
    4. Denial Risk

    Aesthetic Replacement Excluded

    Replacement of implant/abutment supported removable prosthetics for aesthetic reasons is not a covered benefit.

    Denial Risk

    Missing-Tooth Clause May Exclude Treatment

    For plans containing a missing-tooth clause, there is no benefit for replacement of missing teeth when implant/abutment supported removable prosthetics is treatment planned.

    Billing Rule

    Trauma Claims Require Medical-Plan Referral

    Claims for replacement of teeth missing because of an external blow or blunt trauma must first be referred to the subscriber's or employee's medical plan. The medical plan may cover replacement of teeth lost due to accidental injury.

    Removal is limited to a dentist