D6067 Implant Supported Metal Crown (titanium, titanium No No Not Covered alloy, high noble metal) D6068 Abutment Supported Retainer for Porcelain/Ceramic No No Not Covered FPD D6069 Abutment Supported Retainer for Porcelain Fused to No No Not Covered Metal FPD (high noble mental) Abutment Supported Retainer for Porcelain Fused to No No Not Covered Metal FPD (predominantly base metal) Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code age 21 age 21 & under age age 21 & & all over when 21 & all over allowed ICF-IID when residents* under residents allowed 25.04 under 25.04 D6071 Abutment Supported Retainer for Porcelain Fused to No No Not Covered Metal FPD (noble metal) D6072 Abutment Supported Retainer for Cast Metal FPD (high No No Not Covered noble metal) D6073 Abutment Supported Retainer for Cast Metal FPD No No Not Covered (predominantly base metal) Abutment Supported Retainer for Cast Metal FPD No No Not Covered (noble metal) D6075 Implant Supported Retainer for Ceramic FPD No No Not Covered D6076 Implant Supported Retainer for Porcelain to Metal No No Not Covered FPD (titanium, titanium alloy, or high noble metal) D6077 Implant Supported Retainer for Cast Metal FPD No No Not Covered (titanium, titanium alloy, or high noble metal) D6078 Implant/Abutment Supported Fixed Denture for No No Not Covered Completely Edentulous Arch
D6067 Implant Supported Metal Crown (titanium, titanium alloy, high noble metal) No No Not Covered D6068 Abutment Supported Retainer for Porcelain/Ceramic FPD No No Not Covered D6069 Abutment Supported Retainer for Porcelain Fused to Metal FPD (high noble mental) No No Not Covered Abutment Supported Retainer for Porcelain Fused to Metal FPD (predominantly base metal) No No Not Covered Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D6071 Abutment Supported Retainer for Porcelain Fused to Metal FPD (noble metal) No No Not Covered D6072 Abutment Supported Retainer for Cast Metal FPD (high noble metal) No No Not Covered D6073 Abutment Supported Retainer for Cast Metal FPD (predominantly base metal) No No Not Covered Abutment Supported Retainer for Cast Metal FPD (noble metal) No No Not Covered D6075 Implant Supported Retainer for Ceramic FPD No No Not Covered D6076 Implant Supported Retainer for Porcelain to Metal FPD (titanium, titanium alloy, or high noble metal) No No Not Covered D6077 Implant Supported Retainer for Cast Metal FPD (titanium, titanium alloy, or high noble metal) No No Not Covered D6078 Implant/Abutment Supported Fixed Denture for Completely Edentulous Arch No No Not Covered
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