Prosthodontics Section - Fixed Partial Denture:
Pontic, Retainer - (inlay/onlay/crown)
| Topic: Fixed Partial
Denture: Pontic, Retainer - (inlay/onlay/crown) |
Last Reviewed Date:
01/2003 |
| Section: Prosthodontics |
Policy No: 40 |
| Revised/Effective Date: 01/2003
|
Next Review Date: 01/2005 |
IMPORTANT INFORMATION
This Dental Policy has been developed through consideration of
generally accepted standards of dental practice, review of dental literature,
dental necessity, and as appropriate, government approval.
Benefit determinations should be based
in all cases on the applicable contract language.
To the extent there are any conflicts between these guidelines and the
contract language, the contract language will control.
The purpose of dental policy is to provide a guide to coverage. Dental
policy is not intended to dictate to providers how to practice dentistry.
Providers are expected to exercise their clinical judgment in providing
the most appropriate care.
|
Description
Fixed Partial Dentures (D6210 –
D6792):
A fixed partial denture is a prosthetic replacement
of one or more missing teeth cemented or attached
to the abutment or implant adjacent to the space.
D6210 – D6252: fixed partial denture pontics.
Provisional pontic (D6253):
Pontic utilized as an interim of at least six months
duration during restorative treatment to allow adequate
time for healing or completion of other procedures.
This is not to be used a a temporary pontic for routine
prosthetic fixed partial dentures.
D6545 – D6615: fixed partial denture retainers-inlays/onlays.
Policy/Criteria
Procedures are in accordance with generally
accepted standards of dental practice.
Administrative Guidelines
Process to contract benefits.
- Must be reviewed by the dental consultant to establish
dental necessity.
- Number and location of all missing teeth must be
in writing or by radiograph.
- If this is a replacement, the prosthesis must be
more than 7 years old and cannot be made serviceable,
or additional teeth have been lost.
- Temporary appliances are considered in the allowance
for the permanent prosthesis. A separate benefit for
a temporary is not available as a covered benefit.
- Connector bar (D6920) and coping-metal (D6975)
are inclusive and not covered as a separate benefit.
- D6600-D6609: No benefit. Does not meet standard
of case.
| Codes |
Number |
Description |
| CDT |
D5000-D6999 |
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