Criteria
This policy does not apply to Federal Employee Program (FEP) members.
Osseointegrated implants may be eligible for benefits. Written prior approval is required.
The following criteria must be met before approval will be granted:
- An edentulous mandibular arch.
- Severe alveolar atrophy – bone height of less than 15mm, with clinical and radiographic evidence of mental nerve dysesthesia and neuropathy of the mental nerve. (This criteria will be met when documentation is presented that other procedures have been proven unsuccessful in correcting the mental nerve problem.)
- Trials of mandibular prosthesis have failed and there is evidence of problems caused by inability to wear a mandibular dental prosthesis. These may include, but are not limited to, malnutrition, persistent pain, gingival ulcerations and/or mucosal hypertrophy due to instability and upper intestinal problems.
- Evidence presented demonstrates that the individual is able physically and emotionally to care for the implants as natural teeth. If the individual shows poor hygiene and/or would be unable to care for the implants, he/she will not be considered an appropriate candidate.
- Benefits for maxillary implants are limited to use in acute major trauma and structural discontinuity (i.e., tumor resection) individuals only. (The utilization of maxillary implants outside these areas are considered cosmetic dental implants, as most individuals can function with a maxillary prosthesis and no benefits are available).
- Physically handicapped individuals may be considered for placement of osseointegrated implants on special consideration after documentation of medical necessity is provided.
- Partial implant insertion is a non-covered service except if related to dental accident, acute major trauma or structural discontinuity (i.e., tumor resection).
Request for implants when related to dental accident: If the service is related to a dental accident, benefits equal to that available under the dental accident provision of a member’s benefit plan can be applied toward the cost of the dental implants even if the above criteria is not met. After the dental allowance is applied toward the charges, any remaining amounts would then be the subscriber’s responsibility.
Example: The dental allowance of a 3-unit bridge would be available to apply toward the implant cost. Dental accident benefits would still be subject to the definitions, conditions, limitations and exclusions of the member’s Benefit Plan.
When determined to be medically appropriate and necessary benefits are available for stages 1 and 2 reconstruction (the insertion of the implants and the subsequent abutment connection).
Benefits are not available for stage 3 (the crowns or fixed dental bridge attached to the implants) unless due to major trauma or tumor resection.
Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.
Procedure Codes
