Prosthodontics Section - Provisional Retainer
||Date of Origin: January 2003
||Policy No: 41A
|Last Reviewed: January 2015
|Approved: January 2015
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.
Provisional Retainer Crown (D6793):
Retainer crown 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 as a temporary
retainer crown for routine prosthetic fixed partial
Procedure is in accordance with generally accepted
standards of dental practice.
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