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Dental Policy Dental Policy Subject: Implant Crowns and Fixed Partial Dentures Guideline #: 06 -002 Publish Date: 03/15/2018 Status: Revised Last Review Date: 02/05/2018 Description This document addresses the procedures of implant supported crowns, implant supported abutment crowns, and implant supported fixed partial dentures for replacement of missing teeth. Note: Please refer to the following documents for additional information concerning related topics: • Crowns Inlays and Onlays 02-701 • Implants 06-101 • Abutment crowns and Fixed Partial Dentures 06-701 • Clinical Policy-01 Teeth with Poor or Guarded Prognosis Clinical Indications Dental Services using dental implant supported crowns, implant and abutment supported crowns, or implant and/or abutment supported fixed partial dentures to replace missing teeth. May be considered appropriate as a result of: accidental traumatic injuries to sound, natural teeth from an external blow a pathologic disorder; congenitally missing teeth congenital disorders of teeth resulting in extraction. As it applies to appropriateness of care, dental services are: provided by a Dentist, exercising prudent clinical judgment provided to a patient for the purpose of evaluating, diagnosing and/or treating a dental injury or disease or its symptoms in accordance with the generally accepted standards of dental practice which means: o standards that are based on credible scientific evidence published in peer-reviewed, dental literature generally recognized by the practicing dental community o specialty society recommendations/criteria o any other relevant factors clinically appropriate, in terms of type, frequency and extent considered effective for the patient's dental injury or disease not primarily performed for the convenience of the patient or Dentist Not more costly than an alternative service. Dependent on group contract provisions, cosmetic services may not qualify for benefit coverage even though the services may be clinically appropriate. Dental Services using dental implant supported crowns, implant and abutment supported crowns, or implant and/or abutment supported fixed partial dentures are not appropriate in situations where teeth are not missing, including the replacement of third molars. The replacement of multiple teeth by dental implant supported crowns, implant and abutment supported crowns, or implant and/or abutment supported fixed partial dentures in the same arch is not medically necessary (unless specified by group contract) when other less costly dental services are capable of adequately restoring the occlusion to function. The prosthetic restoration of dental implants may be subject to alternate benefit plan provisions. Note: Whether a service is covered by the plan, when any service is performed in conjunction with or in preparation for a non-covered or denied service, all related services are also either not covered or denied. Note: A group may define covered dental services under either their dental or medical plan, as well as to define those services that may be subject to dollar caps or other limits. The plan documents outline covered benefits, exclusions and limitations. The health plan advises dentists and enrollees to consult the plan documents to determine if there are exclusions or other benefit limitations applicable to the service request. The conclusion that a particular service is medically or dentally necessary does not constitute an indication or warranty that the service requested is a covered benefit payable by the health plan. Some plans exclude coverage for services that the health plan considers either medically or dentally necessary. When there is a discrepancy between the health plan’s clinical policy and the group’s plan documents, the health plan will defer to the group’s plan documents as to whether the dental service is a covered benefit. In addition, if state or federal regulations mandate coverage then the health plan will adhere to the applicable regulatory requirement. Note: Dependent upon provider contracts, benefits are payable upon cementation/placement of the permanent crowns or fixed partial dentures. In the event a subscriber does not return for permanent cementation, there is no benefit as the service will be considered incomplete. Criteria 1. Prior to implant placement and restoration, a thorough dental examination, medical and dental history, full mouth imaging, and treatment plan must be completed. 2. As most medical plans include coverage for dental services related to accidental injury, claims for the replacement of missing teeth resulting from an external blow or blunt trauma must first be referred to the subscriber/employee’s medical plan. The medical plan may cover the replacement of missing teeth due to an accidental injury. .. 3. Dependent on provider contract, the delivery date of dental implant supported crowns, implant and abutment supported crowns, or implant and/or abutment supported fixed partial dentures is considered the date of initial placement. 4. If cement is utilized, the type of cement, e.g. permanent or temporary, is not a determinate for the delivery date. 5. Replacement of dental implant supported crowns, implant and abutment supported crowns, or implant and/or abutment supported fixed partial dentures due to “metal allergy/sensitivity” will be considered only upon submission of documentation by a physician with the associated allergy report. 6. A temporary or provisional dental implant supported crowns, implant and abutment supported crowns, or implant and/or abutment supported fixed partial dentures will be considered inclusive with the final restoration. 7. With plans that contain a missing tooth clause where replacement of the tooth/teeth is not covered when extracted and has not been replaced prior to insurance coverage, if the missing teeth to be replaced were removed and not replaced prior to insurance coverage, there is no benefit for the replacement of the missing teeth when dental implant supported crowns, implant and abutment supported crowns, or implant and/or abutment supported fixed partial dentures is treatment planned. 8. When an implant support crown or implant supported fixed partial denture is treatment planned to replace teeth missing with plans that do not have a missing tooth clause, a determination will be made related to the necessity of the implant supported crown or fixed partial denture or if an alternate benefit can be applied which is group contract dependent. In plans with alternate benefit provisions, an alternate benefit may be applied to replace all missing teeth. 9. Documentation for the necessity of dental implant supported crowns, implant and abutment supported crowns, or implant and/or abutment supported fixed partial dentures must include a diagnostic radiographic images. When the necessity for dental implant supported crowns, implant and abutment supported crowns, or implant and/or abutment supported fixed partial dentures coverage is not obvious by radiographic images, the image must be accompanied by additional diagnostic information such as intra-oral photographs of the affected tooth/teeth as well as patient treatment notes and narrative explaining any extraordinary circumstances necessitating crown coverage. 10. Recent diagnostic full mouth or panoramic radiographic images (within the preceding12 months) are required to assess the dental and periodontal health of the entire oral cavity. 11. Tooth-implant supported fixed partial dentures will not be considered for benefits based on meta-analysis and studies that have found this type of combination prosthesis to have a survival rate lower than those reported for solely implant supported or solely tooth supported fixed partial dentures. 12. In the absence of multiple missing teeth within the same arch, implant placement for a second molar tooth may be considered if a functional opposing first or second molar tooth is present. The molar opposing the implant must be periodontally sound and healthy and dependent upon the proposed implant for prevention of passive eruption. 13. A patient’s inability to wear a removable appliance due to severe alveolar ridge atrophy may be considered a qualification for implant placement. This condition must be documented by a letter of dental necessity and planned treatment from the provider and supported by appropriate radiographic evidence. 14. Implant placement will not be considered for correction of developmental or congenital defects (congenitally missing teeth unless covered by group contract) or for spacing due to migration/drifting of teeth. 15. For the replacement of missing teeth that are not covered by the plan, all the above criteria will be applied to the implant supported abutment teeth when there is a missing tooth clause in the group or individual and small group contracts. Note: contracts may include a missing tooth clause or require the plan to apply alternate benefits. Coding The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. CDT Including, but not limited to, the following: D6010 Surgical placement of implant body; endosteal implant D6011 Second stage implant surgery D6013
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