Implants – Dental Coverage Guideline - UHCprovider.com

1 Implants Page 1 of 6 UnitedHealthcare Dental Coverage Guideline Effective 01/01/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. UnitedHealthcare Dental Cover a ge Guideline Implants Guideline Number: Effective Date: January 1, 2022 Instructions for Use Table of Contents Page Coverage Rationale .. 1 Definitions .. 2 Applicable Codes .. 2 Description of Services .. 4 References .. 4 Guideline History/Revision Information .. 5 Instructions for Use .. 5 Coverage Rationale Guidelines for implant placement, subsequent implant supported restorations, and necessary treatment of peri-implant defects: The implant fixture must be osseointegrated prior to loading with final abutment and/or prosthesis Implant must have adequate implant body to crown ratio Must not have more than two threads above the alveolar crest Implant must not be closer than to adjacent roots Same day implant placement at time of extraction considered acceptable Periodontal health of existing dentition must be favorable Long term prognosis must be favorable Site is free of infection Factors to consider in treatment planning for Implants .

2 Location of tooth/teeth Bone quality/quantity Periodontal status of remaining natural teeth Adequate space exists to appropriately restore the implant Patient age ( Implants generally not indicated for patients under age 15) The presence of conditions/treatment that may interfere with the normal healing response. Conditions include, but are not limited to: o Chemotherapy o Radiation therapy to the head and neck o Uncontrolled diabetes and hypertension o Recent heart attack or stroke o Anticoagulant therapy o Blood dyscrasias o IV biophosphonate therapy o Estrogen deficiency Significant psychiatric disorder or impairment Intellectual disability Lifestyle risk factors: o Smoking Related Dental Policies Dental Barrier Membrane Guided Tissue Regeneration Surgical Endodontics Surgical Periodontics: Mucogingival Procedures Surgical Periodontics.

3 Regenerative Procedures Implants Page 2 of 6 UnitedHealthcare Dental Coverage Guideline Effective 01/01/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. o Drug addiction o Alcoholism Definitions Abutment: the fixture that is placed between the implant body (aka implant post) and the restorative prosthesis ( , single crown; denture). (ADA) Dental Implant: A device specially designed to be placed surgically within or on the mandibular or maxillary bone as a means of providing for Dental replacement prosthesis. (ADA) Endosteal (Endosseous): A device placed into the alveolar and basal bone of the mandible or maxilla and transecting only one cortical plate.

4 (ADA) Eposteal (Subperiosteal): A subperiosteal implant that conforms to the superior surface of an edentulous area of alveolar bone. (ADA) Applicable Codes The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this Guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit Coverage for health services is determined by the member specific benefit plan document and applicable laws that may require Coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

5 CDT Code Description D6010 Surgical placement of implant body: endosteal implant D6011 Surgical access to an implant body (second stage implant surgery) D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant D6013 Surgical placement of mini-implant D6040 Surgical placement: eposteal implant D6050 Surgical placement: transosteal implant D6051 Interim implant abutment placement D6055 Connecting bar implant supported or abutment supported D6056 Prefabricated abutment includes modification and placement D6057 Custom fabricated abutment includes placement D6058 Abutment supported porcelain/ceramic crown D6059 Abutment supported porcelain fused to metal crown (high noble metal) D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) D6061 Abutment supported porcelain fused to metal crown (noble metal) D6062 Abutment supported cast metal crown (high noble metal) D6063 Abutment supported cast metal crown (predominantly base metal)

6 D6064 Abutment supported cast metal crown (noble metal) D6065 Implant supported porcelain/ceramic crown D6066 Implant supported porcelain fused to high noble alloys D6067 Implant supported crown high noble alloys D6068 Abutment supported retainer for porcelain/ceramic FPD* D6069 Abutment supported retainer for porcelain fused to metal FPD* (high noble metal) Implants Page 3 of 6 UnitedHealthcare Dental Coverage Guideline Effective 01/01/2022 Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc. CDT Code Description D6070 Abutment supported retainer for porcelain fused to metal FPD* (predominantly base metal) D6071 Abutment supported retainer for porcelain fused to metal FPD* (noble metal) D6072 Abutment supported retainer for cast metal FPD* (high noble metal) D6073 Abutment supported retainer for cast metal FPD* (predominantly base metal) D6074 Abutment supported retainer for cast metal FPD* (noble metal)

7 D6075 Implant supported retainer for ceramic FPD* D6076 Implant supported retainer for FPD* porcelain fused to high noble alloys D6077 Implant supported retainer for metal FPD* - high noble alloys D6080 Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure D6082 implant supported crown porcelain fused to predominantly base alloys D6083 implant supported crown porcelain fused to noble alloys D6084 implant supported crown porcelain fused to titanium and titanium alloys D6085 Interim implant crown D6086 implant supported crown predominantly base alloys D6087 implant supported crown noble alloys D6088 implant supported crown titanium and titanium alloys D6090 Repair implant supported prosthesis, by report D6091 Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis.

8 Per attachment D6092 Re-cement or re-bond implant/abutment supported crown D6093 Re-cement or re-bond implant/abutment supported fixed partial denture D6094 Abutment supported crown titanium and titanium alloys D6095 Repair implant abutment, by report D6096 Remove broken implant retaining screw D6097 abutment supported crown porcelain fused to titanium and titanium alloys D6098 implant supported retainer porcelain fused to predominantly base alloys D6099 implant supported retainer for FPD* porcelain fused to noble alloys D6100 Surgical Removal of implant body D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces.

9 Including flap entry and closure D6103 Bone graft for repair of peri-implant defect does not include flap entry and closure D6104 Bone graft at time of implant placement D6110 Implant/abutment supported removable denture for edentulous arch maxillary D6111 Implant/abutment supported removable denture for edentulous arch mandibular D6112 Implant/abutment supported removable denture for partially edentulous arch maxillary D6113 Implant/abutment supported removable denture for partially edentulous arch mandibular D6114 Implant/abutment supported fixed denture for edentulous arch maxillary D6115 Implant/abutment supported fixed denture for edentulous arch mandibular Implants Page 4 of 6 UnitedHealthcare Dental Coverage Guideline Effective 01/01/2022 Proprietary Information of UnitedHealthcare.

10 Copyright 2022 United HealthCare Services, Inc. CDT Code Description D6116 Implant/abutment supported fixed denture for partially edentulous arch maxillary D6117 Implant/abutment supported fixed denture for partially edentulous arch mandibular D6118 Implant/abutment supported interim fixed denture for edentulous arch mandibular D6119 Implant/abutment supported interim fixed denture for edentulous arch maxillary D6120 implant supported retainer porcelain fused to titanium and titanium alloys D6121 implant supported retainer for metal FPD* predominantly base alloys D6122 implant supported retainer for metal FPD* noble alloys D6123 implant supported retainer for metal FPD* titanium