Medical Policy

Policy Num:     13.005.002
Policy Name:    Implant Services; Crowns, bridges (retainers and Pontics) and Prostheses Supported by Implants
Policy ID:          [13.005.002]  [Ac / L / M+ / P+]  [0.00.00]

Last Review:      October 24, 2024
Next Review:      October 20, 2025
 

Related Policies: None

Implant Services; Crowns, bridges (retainers and Pontics) and Prostheses Supported by Implants

Summary

The crown on implants is a fixed prosthesis that is placed on an osseointegrated implant.

Retainers of bridges / pontics on implants are a series of crowns which replaces one or more edentulous spaces resting on osseointegrated implants. Retainers hold the bridge on top of implants and the pontics are placed in the edentulous spaces.

The prosthesis supported by implant may be complete or partial and they rest on a series of implants returning the functionality of the mouth, restoring mastication and phonetics.

Objective

To return the functionality of the mouth by placing osseointegrated implants restoring with; crowns, crowns/pontics, complete denture or partial denture restoring mastication and phonetics.

Policy Statements

1. Crowns should be predetermined and are subject to the corresponding coinsurances and caps.

2. The implant where the crown will be inserted, must show radiographic evidence of osteointegration and comply with the most recent standards, established by the dental profession.

3. The number of tooth to be used to identify the place of insertion of the crown over an implant will be the area of the missing tooth replaced by the corresponding implant.

4. The replacement of crowns on implants will be considered for replacement, after 5 years have passed, with a proper justification.

5. Partials and dentures over implants are mutually exclusive and cannot be replaced until 5 years have passed.

6. To construct a complete or partial denture over an implant, it includes all procedures, technique, materials, adjustments, repairs and rebases until 6 months after the date of insertion.

7. A complete or partial denture over implant can only be billed after having been inserted. The billing date must coincide with the date of insertion.

8 For those coverages that do not include the benefit of implants but cover crowns on implants, they must comply with the following condition:

It will be an indispensable requirement that there are natural teeth present at both ends of the toothless area making a conventional fixed bridge a viable alternative (see Table of Dental Coverages for this benefit and know the corresponding coinsurances).

Policy Guidelines

1. Radiographic images that shows osseointegrated implant.

2. Corrects implant services codes to be evaluate.

3. Narrative report if necessary.

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

Definition of interest;

Abutment crown

      A crown that retains or support a fixed bridge.

Crown

      A prosthesis that is used to restore a tooth to proper occlusion, contact and contour.

Dental Implants

      Are attachments that replace the root function of a tooth placed in the edentulous spaces to replace the missing teeth.

Denture

       A prosthesis replacing missing teeth.

                a-    Complete denture- prosthesis replacing all the teeth in the arch.

                b-    Partial denture- prosthesis replacing some tooth in the arch or quadrant.

Eposteal implants

       A dental implant that receives its primary support by resting on the bone. Used where advanced bone resorption may prevent the use of endosteal

Implant abutment

       Is the implant that support and retain a fixed prosthesis.

Implant abutment fixed bridge

        A prosthesis that replaces one or more teeth and is cemented to the implant abutment. It consists of one or more pontics held in place by one or more   implant abutments

Implant abutment removable complete denture

        A complete denture that rest on implants abutments instead of resting in the alveolar bone. The denture is fixed but can be removed, giving more stability and comfort.

Pontic

       The part of a fixed bridge that is suspended between abutment replacing missing teeths

Subperiosteal implant

       Implant on top of the bone. Is a metal framework that sits on the jaw bone, but is underneath the gums.

Regulatory Status

N/A

Rationale

Is to return a patient oral health allowing recovering normal masticatory function, aesthetics, speech and comfort.

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 

Individuals: With missing teeth spaces with osseointegrated implant.  Intervention of interest: Single crown Implant /abutment supported.  Comparators of interest: Alveolar supported removable partial denture, fixed bridge (supported by teeth).  Relevant outcomes include: Quality of life, more comfortable, recover normal masticatory function and speech improvement.

Population Reference No. 2 

Individuals: ith missing teeth spaces with osseointegrated implant.  Intervention of interest: Implant/Abutment supported removable complete dentures.  Comparators of interest: Alveolar supported removable denture. Relevant outcomes include: Quality of life, more comfortable, recover normal  masticatory function and speech improvement. 

Population Reference No. 3 

Individuals: With missing teeth spaces with osseointegrated implant. Intervention of interest: Implant/ Abutment supported fixed denture (bridge). Comparators of interest: Alveolar supported removable partial. Relevant outcomes include: Quality of life, more comfortable, recover normal masticatory function and speech improvement.

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. Any dental service that is rendered with purely cosmetic purposes.

b. Any 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 17; Implantes Dentales. (Prosthodontics Quick Consultation Manual, 2013, Section 17; Dental Implants).

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

Codes

Appplicable Modifiers

N/A

Policy History