POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY

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1 Original Issue Date (Created): October 25, 2011 Most Recent Review Date (Revised): January 27, 2015 Effective Date: April 1, 2015 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY I. POLICY A dental implant may be considered medically necessary when all of the following indications are met: It is demonstrated in the clinical record that tooth loss is a direct result of cancer or side effects of cancer treatment; and The remaining tooth and jaw structure are unable to support a functional prosthesis. Cross-reference: NA II. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] Capital Cares 4 Kids [N] PPO [N] HMO [Y] SeniorBlue HMO* [Y] SeniorBlue PPO* [N] Indemnity [N] SpecialCare [N] POS [Y] FEP PPO** Page 1

2 *As indicated under the general exclusions from coverage, items and services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not covered. Structures directly supporting the teeth means the periodontium, which includes the gingivae, dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. **Surgical procedures involving dental implants, except for those required to treat accidental injuries are not covered. An accidental injury is an injury caused by an external force or element such as a blow or fall and that requires immediate attention. Injuries to the teeth while eating are not considered accidental injuries. III. DESCRIPTION/BACKGROUND A dental implant is a small man-made titanium fixture that serves as a replacement for the root portion of a missing natural tooth. A dental implant is composed of three parts: the titanium implant that fuses with the jawbone; the abutment, which fits over the portion of the implant that protrudes from the gum line; and the crown. Titanium is used because it is the most compatible with the human body. The implant is placed in the bone of the upper or lower jaw and functions as an anchor for the replacement tooth/teeth. IV. RATIONALE NA V. DEFINITIONS AVULSION - The complete separation of a tooth from its alveolus, which under appropriate conditions may be reimplanted. The term usually refers to dental injuries resulting from acute trauma. Page 2

3 VI. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VII. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. HCPCS Code D6010 D6040 D6100 Description surgical placement of implant body: endosteal implant surgical placement: eposteal implant; An eposteal (subperiosteal) framework of a biocompatible material designed and fabricated to fit on the surface of the bone of the mandible or maxilla with permucosal extensions which provide support and attachment of a prosthesis. This may be a complete arch or unilateral appliance. Eposteal implants rest upon the bone and under the periosteum. Page 3

4 D6050 D6100 D6199 surgical placement: transosteal implant; A transosteal (transosseous) biocompatible device with threaded posts penetrating both the superior and inferior cortical bone plates of the mandibular symphysis and exiting through the permucosa providing support and attachment for a dental prosthesis. Transosteal implants are placed completely through the bone and into the oral cavity from extraoral or intraoral implant removal, by report Unspecified implant procedure, by report Specific Diagnoses Do Not Apply To This Policy ICD-9-CM Diagnosis Description Code* *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. The following ICD-10 diagnosis codes will be effective October 1, 2015: ICD-10-CM Diagnosis Description Code* *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. IX. REFERENCES Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Publication Chapter15- Covered Medical and Other Health Services. Section 150- Dental Services. 10/17/07. CMS [Website]: Accessed December 29, Dental Implants. American Association of Oral and Maxillofacial Surgeons) [Website]: Accessed December 29, Dental implants-an option for replacing missing teeth. American Dental Association. JADA Volume 136, February Taber s Cyclopedic Medical Dictionary 19th edition. Page 4

5 X. POLICY HISTORY MP CAC 10/25/ New policy. CAC 10/30/12 Consensus review. References updated; no changes to the policy statements. Codes reviewed 10/25/12 klr CAC 1/28/14 Consensus. Added Medicare and FEP variations. CAC 1/27/15 Consensus review. References updated. No changes to the policy statements. Codes reviewed. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 5