ARCHIVED

Medical Policy

Policy Num:     13.002.002
Policy Name:    Fixed Prosthesis
Policy ID:          [13.002.002]  [Ar / L / M+ / P+]  [0.00.00]

Last Review:     October 24, 2024
Next Review:     Policy Archived
 

Related Policies: None

Fixed Prosthesis

Summary

Fixed partial denture is a series of crowns that replace one or more of the edentulous spaces. Retainers or abutments are crowns that hold the bridge on the extremes over the teeth. The pontic is the crown that replaces the edentulous space.

Objective

To restore the relationship between the arches returning the vertical dimensión and replacing missing teeth to restore mastication function.

Policy Statements

All fixed bridges require predetermination. Please refer to the section of Predetermination of Benefits for the requirements related to this process.

Policy Guidelines

1.         To consider a request for predetermination for a fixed bridge, the abutment teeth must comply with the following requirements:

a)    The abutment teeth must be periodontal healthy and free of lesions of endodontic origin (if they have been treated recently for some of these conditions you must include report).

b)    In the case of a tooth, that will be treated endodontally, the canal treatment must be finished before requesting the predetermination and you must send a post operatory radiographic image.

c)     The available abutment teeth must keep proportion with the size of the toothless area.

d)    For "Maryland Bridges" the following codes will be used: For pontic D6211 or D6241 and for each of the retainers, code D6545.

2.         The temporary bridge, its recementation and everything related to it, are part of the fee for the fixed bridge construction procedure.

3.         The time limit to consider a replacement of a fixed prosthesis for payment, is 5 years.

4.         Every request for predetermination for an existing fixed bridge replacement must be accompanied by a detailed report with the clinical findings that justify the necessity of the replacement.

5.         The following are exclusions of fixed prostheses:

a)    Fixed bridges in primary teeth.

b)    Fixed bridges to substitute teeth that have been replaced by a removable partial denture before 5 years.

c)     Fixed bridges for splinting teeth with periodontal problems.

d)    Total reconstructions, except in cases where it is necessary to replace missing teeth or teeth with structural weakness that need crowns as established by the payment policy.

e)    Fixed bridges to correct the vertical dimension or the occlusal plane.

f)      "Cantilever" pontics in which there is no tooth to place a rest.

g)    Fixed bridges where one of the abutment teeth has migrated closing the edentulous area in such a way that does not provide enough space to place a pontic of the size of the tooth to be replaced.

h)    Edentulous spaces that are too big, without abutments reinforcing it, will not be recognized for payment.

    6.    The fixed bridge fee includes all materials, techniques, and procedures necessary to make it such as, and not limited to, temporary, removal of previous                bridge, bases, etc.)

    7.  A fixed bridge predetermined by Triple-S Salud can only be billed after it has been cemented. In other words, the billing date should be the date of                          cementation.

    8.    The request for predetermination of fixed bridges using multiple anchors will be evaluated individually by its merits.

   9.    In a predetermination, when in the same arch at the same time a fixed bridge and a partial is predetermined to substitute teeth in posterior area, only the       

       removable partial will be considered.

   10.    You must send a report of teeth to be removed or evidence of missing teeth in x-rays before approving a fixed bridge.

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

  Abutment;

  Is the tooth that support and retain a fixed prosthesis.

  Cantilever;

   A dental prosthesis that has on or more abutments at one end, the other end being unsupported.

  Crown (artificial)

  A prosthesis that is used to restore a tooth to proper occlusion, contact, and contour. It may be placed as a restoration or as an abutment for a fixed prosthesis.

  Edentulous;

   Without teeth in an area, an arch, or entire mouth.

   Fixed Bridge:

   A prosthesis that replaces one or more teeth and is cemented into place. It consists of one or more pontics held in place by one or more retainers or abutment     teeth.

   Pontic:

    The part of a fixed bridge that is suspended between abutments replacing a missing tooth.

Regulatory Status

N/A

Rationale

To restore the relationship between the arches returning the vertical dimension and replacing missing teeth to restore mastication function when the abutments teeth have a favorable long-term prognosis.

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.

Population Reference No. 1 

Individual: with Partial loss of teeth.  Interventions of interest is: Fixed prosthesis.  Comparators of interest is: Removal prosthesis. Relevant outcomes include: Quality of life More comfort, Better quality of work Restore mastication function.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1.     Participating Odontologist Manual 2024, Rules and Limitations of Retainers and Pontics for Fixed Bridges.

2.     Participating Prosthodontist Manual 2024, Rules and Limitations of Retainers and Pontics for Fixed Bridges.

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

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

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

4.     Richard L. Gorwood, Dentistry and Dental Insurance Claim, 1993, Prosthodontics Removable and Fixed, Implant services, pages 129-131.

5.     Infam Ahmad, Manual de Consulta Rápida en Prostodoncia, 2013, Sección 11; Preparación Dental. (Prosthodontics Quick Consultation Manual, 2013, Section 11; Dental Preparation)

6.     Steven J. Sadousky, Evidence Based Implant Treatment Planning and Clinical Protocols, 2016.

Codes

Appplicable Modifiers

N/A

Policy History