Fixed Prosthodontics
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UnitedHealthcare Dental Coverage Guideline
Effective 12/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
UnitedHealthcare
®
Dental
Coverage Guideline
Fixed Prosthodontics
Guideline Number: DCG017.10
Effective Date: December 1, 2023
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
Fixed Partial Dentures (FPD)
Fixed partial dentures may be indicated for the following:
Replacement of missing permanent teeth in which the Retainer/Abutment teeth have a favorable long-term prognosis
Replacement of one to two missing teeth in a Tooth Bounded Space
In addition to the above, the following applies:
Resin Bonded appliances (e.g., Maryland Bridge) are indicated for the replacement of one missing tooth and
unrestored/undamaged Retainer/Abutment teeth
Fixed partial dentures are not indicated for the following:
Members with rampant caries and/or poor oral hygiene
When Retainer/Abutment teeth have untreated endodontic pathology or periodontal disease or an unfavorable crown: root
ratio
When teeth intended as Retainers/Abutments have inadequate remaining tooth structure
When a tooth to be used as a Retainer/Abutment has tipped or drifted into edentulous space
Cantilever and Resin Bonded fixed partial dentures (Maryland Bridge) are not indicated for the following:
o In an area with malocclusion, heavy occlusion or parafunctional habits (e.g., nail biting, bruxism, clenching)
o A Pontic width discrepancy
o Additionally, Resin Bonded appliances are not indicated in the following situations:
Compromised enamel
Deep vertical overlap
Provisional Fixed Partial Dentures
Provisional fixed partial dentures may be indicated for the following:
When a permanent fixed partial denture does not have a favorable long-term prognosis
To replace a lost tooth in young members to allow maturity of the dentition and jaws before constructing a definitive fixed
prosthetic appliance
When a systemic medical condition prohibits the placement of a definitive fixed prosthetic appliance
Related Dental Policy
•
Removable Prosthodontics
Fixed Prosthodontics
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Fixed Partial Denture Repair (Necessitated by Restorative Material Failure)
Fixed partial denture repair may be indicated when the appliance to be repaired is functional and has a favorable long-
term prognosis.
Precision Attachments
Precision Attachments may be indicated for the following:
When aesthetics need to be considered
For the redistribution of occlusal forces
To minimize trauma to soft tissue
Control of loading and rotational forces
When it is not possible to prepare two Retainers/Abutments with a common path of placement
Connector Bar
Connector Bars may be indicated to brace individual Retainer/Abutment teeth with considerable coronal length for
enhanced stabilization of removable partial dentures, complete dentures and overdentures.
Stress Breaker (A Non-Rigid Connector)
Stress Breakers may be indicated for the following:
When it is not possible to prepare two Retainers/Abutments with a common path of placement
When the prognosis of a Retainer/Abutment is uncertain
Control of loading and rotational forces
Redistribution of occlusal forces
Definitions
Abutment: That part of a structure that directly receives thrust or pressure; an anchorage 2: a tooth, a portion of a tooth, or that
portion of a dental implant that serves to support and/or retain prosthesis. (AP)
Cantilever Fixed Dental Prosthesis: A Fixed complete or partial denture in which the Pontic is cantilevered, (i.e., is retained
and supported only on one end by one or more Abutments). (AP)
Connector Bar: A device attached to fixed partial denture Retainer or coping which serves to stabilize and anchor a removable
overdenture prosthesis. (ADA)
Fixed Dental Prosthesis: The general term for any prosthesis that is securely fixed to a natural tooth or teeth, or to one or more
dental implants/implant abutments; it cannot be removed by the patient. (AP)
Pontic: An artificial tooth on a Fixed Dental Prosthesis that replaces a missing natural tooth, restores its function, and usually
fills the space previously occupied by the clinical crown. (AP)
Precision Attachment: An interlocking device, one component of which is fixed to an Abutment or Abutments, and the other is
integrated into a removable dental prosthesis in order to stabilize and/or retain it. (AP)
Resin-Bonded Prosthesis (e.g., Maryland Bridge): A Fixed Dental Prosthesis that is luted to tooth structures, primarily
enamel, which has been etched to provide mechanical retention for the resin cement. (AP)
Retainers: Any type of device used for the stabilization or retention of prosthesis. (AP)
Tooth Bounded Space: A space created by one or more missing teeth that has a tooth on each side. (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
Fixed Prosthodontics
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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.
CDT Code
Description
D6205
Pontic – indirect resin-based composite
D6210
Pontic – cast high noble metal
D6211
Pontic – cast predominantly base metal
D6212
Pontic – cast noble metal
D6214
Pontic – titanium and titanium alloys
D6240
Pontic – porcelain fused to high noble metal
D6241
Pontic – porcelain fused to predominantly
D6242
Pontic – porcelain fused to noble metal
D6243
Pontic – porcelain fused to titanium and titanium alloys
D6245
Pontic – porcelain/ceramic
D6250
Pontic – resin with high noble metal
D6251
Pontic – resin with predominantly base metal
D6252
Pontic – resin with noble metal
D6253
Interim pontic- further treatment or completion of diagnosis necessary prior to final impression
D6545
Retainer – cast metal for resin bonded fixed prosthesis
D6548
Retainer – porcelain/ceramic for resin bonded fixed prosthesis
D6549
Resin retainer – for resin bonded fixed prosthesis
D6600
Retainer inlay – porcelain/ceramic, two surfaces
D6601
Retainer inlay – porcelain/ceramic, three or more surfaces
D6602
Retainer inlay – cast high noble metal, two surfaces
D6603
Retainer inlay – cast high noble metal, three or more surfaces
D6604
Retainer inlay – cast predominantly base metal, two surfaces
D6605
Retainer inlay – cast predominantly base metal, three or more surfaces
D6606
Retainer inlay – cast noble metal, two surfaces
D6607
Retainer inlay – cast noble metal, three or more surfaces
D6608
Retainer onlay – porcelain/ceramic, two surfaces
D6609
Retainer onlay – porcelain/ceramic, three or more surfaces
D6610
Retainer onlay – cast high noble metal, two surfaces
D6611
Retainer onlay – cast high noble metal, three or more surfaces
D6612
Retainer onlay – cast predominantly base metal, two surfaces
D6613
Retainer onlay – cast predominantly base metal, three or more surfaces
D6614
Retainer onlay – cast noble metal, two surfaces
D6615
Retainer onlay – cast noble metal, three or more surfaces
D6624
Retainer inlay – titanium
D6634
Retainer onlay – titanium
D6710
Retainer crown – indirect resin-based composite
D6720
Retainer crown – resin with high noble metal
D6721
Retainer crown – resin with predominantly base metal
D6722
Retainer crown – resin with noble metal
Fixed Prosthodontics
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CDT Code
Description
D6740
Retainer crown – porcelain/ceramic
D6750
Retainer crown – porcelain fused to high noble metal
D6751
Retainer crown – porcelain fused to predominantly base metal
D6752
Retainer crown – porcelain fused to noble metal
D6753
Retainer crown – porcelain fused to titanium and titanium alloys
D6780
Retainer crown – 3/4 cast high noble metal
D6781
Retainer crown – 3/4 cast predominantly base metal
D6782
Retainer crown – 3/4 cast noble metal
D6783
Retainer crown – 3/4 porcelain/ceramic
D6784
Retainer crown – 3/4 titanium and titanium alloys
D6790
Retainer crown – full cast high noble metal
D6791
Retainer crown – full cast predominantly base metal
D6792
Retainer crown – full cast noble metal
D6793
Interim retainer crown- further treatment or completion of diagnosis necessary prior to final impression
D6794
Retainer crown – titanium and titanium alloys
D6920
Connector bar
D6930
Re-cement or re-bond fixed partial denture
D6940
Stress breaker
D6950
Precision attachment
D6980
Fixed partial denture repair necessitated by restorative material failure
D6985
Pediatric partial denture, fixed
D6999
Unspecified fixed prosthodontic procedure, by report
CDT
®
is a registered trademark of the American Dental Association
Description of Services
Fixed prosthodontics is the area of restorative dentistry that involves the replacement of missing teeth with custom made
restorations that are permanently cemented and not removable. The term “fixed partial denture” is synonymous with “fixed
bridge” or “bridgework”. The restoration used to replace a missing tooth is called a pontic and the restorations placed on teeth
on either side of it are called retainer restorations or abutments and are typically an onlay or a crown. There is some controversy
regarding connecting natural teeth to implants with fixed prostheses. During function, the natural tooth has slight movement
due to the presence of the periodontal ligament, while the implant is completely osseointegrated and does not move. This can
create stress at the neck of the implant result in possible fracture, breakdown of osseointegration, and loosening of the implant
and its components (Yilmaz). This type of restoration may be the best option in some situations and the decision should be
made based on individual patient needs. (Al-Omiri). Cantilever and Resin Bonded bridges consist of a pontic that is bonded to
an adjacent teeth/tooth that have not been restored with an indirect restoration.
References
Academy of Prosthodontists The Glossary of Prosthodontic Terms. Ninth Edition.
Alenezi A, Aloqayli S. Technical complications with tooth-supported fixed dental prostheses (FDPs) of different span lengths: an
up to 15-year retrospective study. BMC Oral Health. 2023 Jun 15;23(1):393.
Al-Omiri MK, Al-Masri M, Alhijawi MM, et al. Combined Implant and Tooth Support: An Up-to-Date Comprehensive Overview. Int
J Dent. 2017;2017.
American College of Prosthodontists (ACP). Parameters of Care for the Specialty of Prosthodontics. Partial Edentulism
Parameter. 2020., https://www.prosthodontics.org/assets/1/7/ACP_Parameters_of_Care_2020.pdf
. Accessed October 2, 2023
Fixed Prosthodontics
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UnitedHealthcare Dental Coverage Guideline
Effective 12/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
American Dental Association (ADA) CDT Codebook 2023.
American Dental Association (ADA) Glossary of Clinical and Administrative Terms.
Heyman H. Sturdevant’s Art and Science of Operative Dentistry, 6th ed. St. Louis: Mosby c2013. Online Chapter 21, Bonded
Splints and Bridges; p.e148.
Nesbit S, Kanjirath P, Stefanac S. Diagnosis and Treatment Planning in Dentistry, 4th ed. St. Louis: Elsevier c2024. Chapter 11,
The Definitive Phase of Treatment; p.246-288.
Rosenstiel S, Land M, Fujimoto J. Contemporary Fixed Prosthodontics, 5th ed. St. Louis: Mosby c2016. Part 1: Planning and
Preparation, Chapter 3 Treatment Planning; p.77-85.
Thompson V. Contemporary Fixed Prosthodontics, 5th ed. St. Louis: Mosby c2016. Part III: Laboratory Procedures, Chapter 26
Resin Bonded Fixed Dental Prostheses; p.694-702.
Yilmaz B, McGlumphy E. Contemporary Fixed Prosthodontics, 5th ed. St. Louis: Mosby c2016. Chapter 13, Implant Supported
Fixed Prostheses; Connecting Implants to Natural Teeth; p359.
Guideline History/Revision Information
Date
Summary of Changes
02/01/2024
Template Update
Updated
Instructions for Use
to clarify this policy applies to both Commercial and Medicare
Advantage plans
12/01/2023
Coverage Rationale
Removed content addressing coverage limitations and exclusions
Supporting Information
Updated
Description of Services
and
References
sections to reflect the most current information
Archived previous policy version DCG017.09
Instructions for Use
This Dental Coverage Guideline provides assistance in interpreting UnitedHealthcare standard and Medicare Advantage dental
plans. When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member
specific benefit plan may differ from the standard dental plan. In the event of a conflict, the member specific benefit plan
document governs. Before using this guideline, please check the member specific benefit plan document and any applicable
federal or state mandates. UnitedHealthcare reserves the right to modify its Policies and Guidelines as necessary. This Dental
Coverage Guideline is provided for informational purposes. It does not constitute medical advice.
