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Medical Policy

Policy Num:      13.002.001
Policy Name:    Removable Prostheses; Complete and Partial Removable Dentures
Policy ID:          [13.002.001]  [Ar / L / M+ / P-]  [0.00.00]

Last Review:      October 26, 2023
Next Review:      Policy Archived

ARCHIVED
 

Related Policies: None

Removable Prostheses; Complete and Partial Removable Dentures

Summary

It is an artificial removable device designed to restore the anatomy of one, several or all the teeth, restoring the relationship between the arches (maxillary and mandibular) returning the vertical dimension and replacing missing teeth. Complete denture; is the complete removable prosthesis muco supported for edentulous patients (total toothless). Partial dentures; is the removable prosthesis that replaces one or more teeth missing from a dental arch.

Objective

The objective of the removable prostheses is to recover the functionality of the mouth restoring mastication and phonetics.

Policy Statements

All removable dentures; complete or partial, require predetermination in the line of buisiness Advantage and, Comercial line of Buisness  Federal, (D-41). (See dental coverage table for those that do not require predetermination).

Policy Guidelines

   1. The benefit of complete or partial dentures is limited to payment to one per arch every 5 years.

2. The fee to construct a complete or partial removable denture includes all procedures, techniques and materials. In addition, includes all adjustments, repairs and rebase up to 6 months after the date of insertion.

3.   If the insured needs an all metal partial denture, it must be billed using codes D5213 or D5214 (maxillary and mandibular partial dentures respectively), in conjunction with the D5899 code along with a report justifying making them all in metal and the corresponding coinsurances, will be applied.

4.   A complete or partial denture may only be billed after it has been inserted. In other words, the billing date must coincide with the date of  insertion.

5.   For codes D5282 and D5283 it must indicate:

     a.  It will only be paid one unilateral every 5 years and it will be billed using the quadrant number. This would exhaust for 5 years one partial denture in the corresponding arch.

      b-  If you request in the same arch two unilateral, it will only be considered for payment one bilateral to replace the missing teeth.

      c-   In the report or charting you must indicate the number of tooth to be replaced.

Benefit Application

BlueCard/National Account Issues - N/A

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Definitions of interest;

 Dental Prosthesis

 Artificial replacement for one or more natural teeth and or associated structures. The prosthesis could be fixed dental prosthesis or removable.

 Fixed Partial Denture

 A prosthesis that replace one or more teeth and is cemented on place on a abutment teeth or implant replacement.

 Immediate Denture

 A complete or partial denture that is made before the natural teeth are extracted. It is inserted at the time the teeth are extracted.

 Implant Supported Denture

 Complete or partial denture that is supported on implants body instead of resting in the alveolar ridge.

 Removable Complete Denture

 Is a dental prosthesis that replaces all the natural teeth (dentition) and associated structures of the maxilla or mandible.

 Removable Partial denture

 Is a dental prosthesis that replaces one or more natural teeth on the arch or quadrant in the maxilla or mandible.

Regulatory Status

N/A

Rationale

Removal Prostheses (Complete and Partial Dentures) are indicated for replacement of loss of teeth caused by periodontal or cavities disease or injury (trauma).

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American];LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflectiveof and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g.,women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Complete Denture is indicated for the following;

1-    To replace teeth when teeth are loss due to cavities or periodontal disease

2-    To replace teeth loss by injury(trauma)

3-    To replace teeth due to other disease as and not limited to cancer, congenital defects or surgery needing mouth reconstruction

Partial denture is indicated for the following;

1-    To replace teeth when teeth are loss due to cavities or periodontal disease.

2-    To replace teeth loss by injury(trauma)

3-    When fixed denture is contraindicated.

To replace teeth due to other disease as and not limited to cancer, congenital defects or surgery needing mouth reconstruction

Population Reference No. 1 

Individual: with Edentolous arch (complete loss of teeth in the arch). Interventions of interest is: Removable prosthesis (Complete denture). Comparators of interest are: Implants, Implants supported complete denture. Relevant outcomes include: Less Cost, Quality of life,Reestablish masticatory function

Population Reference No. 2 

Individual: with Edentolous arch (complete loss of teeth in the arch). Interventions of interest is: Removable próstesis (Partial Denture). Comparators of interest are: Implants, Fixed bridge. Relevant outcomes include: Less Cost, Quality of life, Reestablish masticatory function.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1. Participating Odontologist Manual 2023, Rules and Limitations for Complete and Partial Dentures.

2. Participating Prosthodontist Manual 2023, Rules and Limitations for Complete and Partial Dentures.

3. Insured’s certificate of coverage, exclusions of the dental coverage.

a. Every service not included as covered service in the description of coverage.

b. Every dental service that is rendered with purely cosmetic purposes.

4. Richard L. Gorwood, Dentistry and Dental Insurance Claim, 1993, Prosthodontics Removable and Fixed, Removable Prosthodontics, pages 117-128.

5. Infam Ahmad, Manual de Consulta Rápida en Prostodoncia, 2013, Sección 16; Prótesis Removible. (Prosthodontics Quick Consultation Manual, 2013; Section 16, Removable Prosthesis)

Codes

Appplicable Modifiers

N/A

Policy History