Implant/Abutment Supported Fixture Denture for NO NO Not Covered Partially Edentulous Arch OTHER IMPLANT SERVICES Implant Maintenance Procedures, when Prostheses are No No Not Covered Removed and Reinserted, Including Cleansing of Prostheses and Abutments D6090 Repair Implant Supported Prosthesis, by Report No No Not Covered Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code under age 21 age 21 & under age 21 age 21 & & all over when & all over allowed when residents* under residents allowed 25.04 under 25.04 D6091 Replacement of Semi-precision or Precision Attachment NO NO Not Covered (male or female component) of Implant/Abutment Supported Prosthesis, per Attachment D6092 Recement Implant/Abutment Supported Crown NO NO Not Covered D6093 Recement Implant/Abutment Supported Fixed Partial NO NO Not Covered Denture D6094 Abutment Supported - (titanium) NO NO Not Covered D6095 Repair Implant Abutment, by Report No No Not Covered D6100 Implant Removal, by Report No No Not Covered D6101 Debridement of a periimplant defect and surface NO NO Not Covered cleaning of exposed implant surfaces, including flap entry and closure
Implant/Abutment Supported Fixture Denture for Partially Edentulous Arch NO NO Not Covered OTHER IMPLANT SERVICES Implant Maintenance Procedures, when Prostheses are Removed and Reinserted, Including Cleansing of Prostheses and Abutments No No Not Covered D6090 Repair Implant Supported Prosthesis, by Report No No Not Covered Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all residents age 21 & over when allowed under 25.04 D6091 Replacement of Semi-precision or Precision Attachment (male or female component) of Implant/Abutment Supported Prosthesis, per Attachment NO NO Not Covered D6092 Recement Implant/Abutment Supported Crown NO NO Not Covered D6093 Recement Implant/Abutment Supported Fixed Partial Denture NO NO Not Covered D6094 Abutment Supported - (titanium) NO NO Not Covered D6095 Repair Implant Abutment, by Report No No Not Covered D6100 Implant Removal, by Report No No Not Covered D6101 Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure NO NO Not Covered
c3s025.docx