BlueCross and BlueShield of Montana Medical Policy
Medical Policy

Dental: Implants

 

Chapter: Dental

© Blue Cross and Blue Shield of Montana

 

Current Effective Date: 05/17/2007
Original Effective Date: 05/17/2007

 

Description

A dental implant is an artificial replacement for natural tooth roots implanted into the bone and gum tissue to become a stable base for a crown. Implants are made of titanium and other materials compatible with human tissue.


Replacement of a tooth with an implant may begin with extraction of a diseased or broken tooth. Sometimes bone grafting is done at the time of the extraction to prepare an adequate site for the implant. The implant is then surgically implanted in the bone and will stay covered by gum tissue for three to six months while it fuses with the bone in a process called
osseointegration. In the next step, the implant is uncovered and an extension, called a post or abutement, is attached. With some implants the abutement and implant are a single unit and placed during the initial surgery. In the final step, a crown is fitted over the abutement.

Policy

Benefits for dental implants are contract specific.


NOTE: Treatment of congenitally missing teeth is considered dental and coverage for implants will only be allowed if the member has dental implant coverage.


Prior authorization is recommended for dental implants that are the result of an accident. Please call BCBSMT customer service at 1-800-447-7828 or fax your request to the medical review department at 406-437-7863. A retrospective review will be done if services are not prior authorized.

• Blue Cross and Blue Shield of Montana (BCBSMT) may allow coverage of implants under medical benefits when loss or irreparable damage to the tooth, or teeth, is the result of an accident. See the policy: "Dental Accident."

Rationale for Benefit Administration

This dental policy was developed through consideration of peer reviewed dental literature, FDA approval status, accepted standards of dental practice in Montana, Technology Evaluation Center evaluations, other Blue Cross and Blue Shield plan policies and the concept of medical necessity.

The purpose of dental policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their dental judgment. Blue Cross and Blue Shield of Montana
recognizes the rapidly changing nature of technological development and welcomes provider feedback on all dental policies.

When using this policy to determine whether a service, supply or device will be covered please note that member contract language will take precedence over dental policy when there is a conflict.


Coding

CPT Codes

21210
GFT BONE; NASAL/MAXIL/MALAR AREAS
21215
GFT BONE; MANDIB

CDT Codes

D6010 - Surgical placement of implant body:
endosteal implant
D6012 - Surgical placement of interim implant body for transitional prosthesis:
endosteal implant
D6040 - Surgical placement:
eposteal implant
D6050 - Surgical placement:
transosteal implant

Implant supported prosthetics:

D6053 - Implant/abutment supported removable denture for completely
edntulous arch
D6054 - Implant/abutment supported removable denture for partially
endentulous arch
D6055 - Dental implant supported connecting bar

D6056 - Prefabricated abutment - includes placement

D6057 - Custom abutment - includes placement

D6058 - Abutment Supported porcelain/ceramic crown

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)

D6094 - Abutment supported crown - (titanium)

D6065 - Implant supported porcelain/ceramic crown

D6066 - Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)

D6067 - Implant supported metal crown (titanium, titanium alloy, high noble metal)

D6068 -
Abutement supported retainer for porcelain/ceramic FPD
D6069 - Abutment supported retainer for porcelain fused to metal FPD (high noble metal)

D6070 - Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)

D6071 - Abutment supported retainer for porcelain fused to metal FPD (noble metal)

D6072 - Abutment supported retainer for
acst metal FPD (high noble metal)
D6073 - Abutment supported retainer for cast metal FPD (predominantly base metal)

D6074 - Abutment supported retainer for cast metal FPD (noble metal)

D6194 - Abutment supported retainer crown for FPD - (titanium)

D6075 - Implant supported retainer for ceramic FPD

D6076 - Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)

D6077 - Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)

D6078 - Implant/abutment supported fixed denture for completely edentulous arch

D6079 - Implant/abutment supported fixed denture for partially edentulous arch


Other implant services:

D6080 - Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis

D6090 - Repair implant supported prosthesis, by report

D6091 - Replacement of semi-
precison or precison attachment (male or female component) of implant/abutment supported prosthesis, per attachment
D6092 -
Recement implant/abutment supported crown
D6093 -
Recement implant/abutment suported fixed partial denture
D6095 - Repair implant abutment, by report

D6100 - Implant removal, by report

D6190 - Radiographic/surgical implant index, by report

D6199 - Unspecified implant procedure, by report


References

1.Dental implants an option for replacing misssing teeth. American Dental Association. http://www.ada.org/prof/resources/pubs/jada/patient/patient_47.pdf Accessed September 6, 2005.

2.Regence Dental Policy. http://www.regence.com/about/dental/prosthodontics/index.html Accessed September 6, 2005.

 

CDT only © American Dental Association.



®Registered Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

 

 

History of Development

 
An independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Dental: Implants Dental: Implants