POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY
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1 Original Issue Date (Created): 1/1/2012 Most Recent Review Date (Revised): 1/18/2018 Effective Date: 8/1/2018 RETIRED POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY I. POLICY Dental implants may be considered medically necessary when major disease, trauma, or surgery results in insufficient boney structure to support dentures or other oral prosthetics in order to chew. Cross-reference: NA II. PRODUCT VARIATIONS This policy is applicable to all programs and products administered by Capital BlueCross unless otherwise indicated below. FEP PPO - Dental implants are covered only when reported in relation to an accidental injury or restoring the mouth to a pre-cancerous state. III. DESCRIPTION/BACKGROUND A dental implant is a small man-made titanium fixture that serves as a replacement for the root portion of a missing natural tooth. A dental implant is composed of three parts: the titanium implant that fuses with the jawbone; the abutment, which fits over the portion of the implant that protrudes from the gum line; and the crown. Titanium is used because it is the most compatible with the human body. The implant is placed in the bone of the upper or lower jaw and functions as an anchor for the replacement tooth/teeth. IV. RATIONALE NA Page 1
2 V. DEFINITIONS AVULSION - The complete separation of a tooth from its alveolus, which under appropriate conditions may be reimplanted. The term usually refers to dental injuries resulting from acute trauma. VI. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital BlueCross for benefit information. VII. DISCLAIMER Capital BlueCross s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital BlueCross considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. Page 2
3 HCPCS Code D6010 D6040 D6050 D6051 D6052 D6055 D6056 D6057 D6058 D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6080 D6085 D6090 D6091 D6092 D6093 D6094 Description surgical placement of implant body: endosteal implant surgical placement: eposteal implant surgical placement: transosteal implant interim abutment semi-precision attachment abutment connecting bar - implant supported or abutment supported prefabricated abutment - includes modification and placement custom fabricated abutment - includes placement abutment supported porcelain/ceramic crown abutment supported porcelain fused to metal crown (high noble metal) abutment supported porcelain fused to metal crown (predominantly base metal) abutment supported porcelain fused to metal crown (noble metal) abutment supported cast metal crown (high noble metal) abutment supported cast metal crown (predominantly base metal) abutment supported cast metal crown (noble metal) implant supported porcelain/ceramic crown implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) implant supported metal crown (titanium, titanium alloy, high noble metal) abutment supported retainer for porcelain/ceramic FPD abutment supported retainer for porcelain fused to metal FPD (high noble metal) abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) abutment supported retainer for porcelain fused to metal FPD (noble metal) abutment supported retainer for cast metal FPD (high noble metal) abutment supported retainer for cast metal FPD (predominantly base metal) abutment supported retainer for cast metal FPD (noble metal) implant supported retainer for ceramic FPD implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments Provisional implant crown repair implant supported prosthesis, by report replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment re-cement or re-bond implant/abutment supported crown re-cement or re-bond implant/abutment supported fixed partial denture abutment supported crown - (titanium) Page 3
4 HCPCS Code Description D6095 repair implant abutment, by report D6199 Unspecified implant procedure, by report Specific Diagnoses Do Not Apply To This Policy IX. REFERENCES Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Publication Chapter15- Covered Medical and Other Health Services. Section 150- Dental Services. 10/17/07. CMS [Website]: Accessed February 14, Dental Implants. American Association of Oral and Maxillofacial Surgeons. [Website]: Accessed February 14, Dental implants-an option for replacing missing teeth. American Dental Association. JADA Volume 136, February Taber s Cyclopedic Medical Dictionary 19th edition. X. POLICY HISTORY MP CAC 10/25/ New policy. CAC 10/30/12 Consensus review. References updated; no changes to the policy statements. Codes reviewed 10/25/12. CAC 1/28/14 Consensus. Added Medicare and FEP variations. CAC 1/27/15 Consensus review. References updated. No changes to the policy statements. Codes reviewed. CAC 1/26/16 Consensus review. No change to policy statements. References updated. Coding reviewed. Admin update 1/1/17: Product variation section reformatted. New code D6085 added; effective 1/1/17. CAC 3/28/17 Minor review. Changed policy statement to be consistent with the COC. References reviewed. Coding Reviewed. 1/1/18 Admin Update: Medicare variations removed from Commercial Policies. 1/18/18 Review for retirement. COC indicates non-coverage for dental implants. Coding reviewed. Retired effective 8/1/18. Page 4
5 Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 5
EFFECTIVE DATE: 04/24/14 REVISED DATE: 04/23/15, 04/28/16, 06/22/17, 06/28/18 POLICY NUMBER: CATEGORY: Dental
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