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Medical Policy

Policy Num:      13.002.003
Policy Name:     Other Fixed Partial Dentures Services
Policy ID:          [13.002.003]  [Ar / L / M+ / P+]  [0.00.00]

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

ARCHIVED
 

Related Policies: None

Other Fixed Partial Dentures Services

Summary

They are components that help with the construction of fixed partial dentures when the condition or position of the teeth does not help to perform it the conventional way.

 These techniques help when:

Stress breaker are used as an integral part of a partial denture that will enable the operator to limit the movements between the clasps on the abutment teeth and the free end saddle to such a degree that the movement will be within the physiologic tolerance of the underlying tissues and equalize the stress between the abutment teeth and edentulous area Precision Attachment is use when the abutment is at an angle out of the parallelism of the passage  of insertion.

Objective

Components to aid with the construction of a fixed partial denture when the condition or position of teeth does not help or permit to perform in the conventional way.

Policy Statements

    Rules and limitations for other fixed partial dentures services:

      1.     Code D6940 Stress breaker and D6920, required predetermination and will be considered for payment one by arch every 5 years.

2.     Procedure code D6950 precision attachment requires predetermination and is considered for payment one by quadrant every 5 years.

Policy Guidelines

        When the fixed partial denture can’t be constructed in the conventional way and needs the aids of  this component.

 Considered for payment one by arch every 5 years.

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

   They are components that help with the construction of fixed partial dentures when the condition or position of the teeth does not help to perform it the conventional way.

   Definition of interest;

Abutment

   A tooth that retain or support a fixed bridge or removable prostheses.

Fixed Bridge

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

Precision Attachment

   A specially designed attachment used in fixed and removable prostheses  to lock the denture onto the natural teeth.

Pontic

  The part of affixed bridge that is suspended between abutments replacing the missing tooth teeth. It consists of a tongue and groove, or male/ female, design.

Stressbreaker 

  An attachment that is incorporated into a removable partial denture or fixed bridgework to relieve  pressure on the abutment teeth.

Regulatory Status

N/A

Rationale

Help the integrity of a fixed bridge between the abutment and the edentulous areas.

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 Missing teeth with problems of stress in fixed partial denture between the abutment and edentulous area. Intervention of interest is: Other fixed partial denture services (Stress breaker). Comparators of interest: is: Fixed bridge without stress breaker. Relevant outcomes include:

  Stress breaker in fixed bridge eliminating possibilities of fracture of bridge. Protection of periodontal    

  problems on abutments teeth.

Population Reference No. 2 

Individual: with Missing teeth with problems with parallelism in the angle of insertion on abutment for fixed partial denture.  Intervention of interest is: Other fixed partial denture services (precision attachment). Comparators of interest: is: Fixed bridge without precision attachment. Relevant outcomes include: Solving parallelism problems between abutment teeth and edentulous areas. Protection in tooth structure in abutments teeth.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1. Participating Odontologist Manual 2023, Fixed Prosthodontics; other services of fixed partial dentures:

                     Rules and limitations, for other fixed partial dentures services.

2. Participating Prosthodontist Manual 2023, Fixed Prosthodontics; Other services of fixed partial

    dentures; Rules and limitations, for other fixed partial dentures services.

3. Richard L. Garwood, Dentistry and Dental Insurance Claim 199. Other Fixed Prosthetics Services,        

     pages 135-136.

Codes

Appplicable Modifiers

N/A

Policy History