# missing tooth clause dental insurance Answer: A missing tooth clause is a plan term that bars payment for replacing a tooth that was lost or extracted before the current coverage started — the payer's own definition, from Delta Dental of New Jersey. It is a contract term, not a payer policy, and it is not universal: of the plan documents and payer policies read for this page, one Guardian individual plan in Utah carries a missing teeth limitation with a narrow carve-out (extraction within 12 months of the effective date and while covered under a prior plan), MetLife's group plan-summary form writes five separate prosthetic exclusions with a written-in carve-out for congenitally missing teeth, and Aetna's federal FEDVIP brochure states the same idea positively as the Tooth Missing but Not Replaced Rule. The TRICARE Dental Program, United Concordia's FEDVIP brochure, one Delta Dental Insurance Company group PPO, one Cigna Pennsylvania individual plan, and Colorado Medicaid carry no such clause at all, and Delta Dental of New Jersey publishes the opposite — a Missing Tooth Inclusion for members aged 16 and over on plans that cover restorative work. Three instruments are routinely mistaken for it: a replacement rule keyed to when the extraction happened relative to an existing prosthesis, a frequency-clock carryover that counts prior-carrier service dates, and an arch-level prosthodontic cap. There is no certificate of creditable coverage to submit: 45 CFR 146.115 superseded that artifact for periods beginning December 31, 2014, and stand-alone dental was never in its scope as an excepted benefit under 45 CFR 146.145(b). Answer URL: https://dentovio.com/answers/dental-plan-terms-missing-tooth Markdown mirror: https://dentovio.com/answers/dental-plan-terms-missing-tooth/index.html.md Source page: [/dental-missing-tooth-clause](https://dentovio.com/dental-missing-tooth-clause) Source markdown: [/dental-missing-tooth-clause/index.html.md](https://dentovio.com/dental-missing-tooth-clause/index.html.md) Topic page: [/answers/topic/practice-operations-tools](https://dentovio.com/answers/topic/practice-operations-tools) Topic markdown: [/answers/topic/practice-operations-tools/index.html.md](https://dentovio.com/answers/topic/practice-operations-tools/index.html.md) Answer hub: [Dentovio Public Answers](https://dentovio.com/answers) Answer bank JSON: https://dentovio.com/answer-bank.json Answer intent ID: `dental-plan-terms-missing-tooth` Cluster: Practice operations Last verified: 2026-08-31 Reviewer: none — owner-published, verified against the primary sources cited here and not reviewed by a credentialed specialist. ## Direct answer A missing tooth clause is a plan term that bars payment for replacing a tooth that was lost or extracted before the current coverage started — the payer's own definition, from Delta Dental of New Jersey. It is a contract term, not a payer policy, and it is not universal: of the plan documents and payer policies read for this page, one Guardian individual plan in Utah carries a missing teeth limitation with a narrow carve-out (extraction within 12 months of the effective date and while covered under a prior plan), MetLife's group plan-summary form writes five separate prosthetic exclusions with a written-in carve-out for congenitally missing teeth, and Aetna's federal FEDVIP brochure states the same idea positively as the Tooth Missing but Not Replaced Rule. The TRICARE Dental Program, United Concordia's FEDVIP brochure, one Delta Dental Insurance Company group PPO, one Cigna Pennsylvania individual plan, and Colorado Medicaid carry no such clause at all, and Delta Dental of New Jersey publishes the opposite — a Missing Tooth Inclusion for members aged 16 and over on plans that cover restorative work. Three instruments are routinely mistaken for it: a replacement rule keyed to when the extraction happened relative to an existing prosthesis, a frequency-clock carryover that counts prior-carrier service dates, and an arch-level prosthodontic cap. There is no certificate of creditable coverage to submit: 45 CFR 146.115 superseded that artifact for periods beginning December 31, 2014, and stand-alone dental was never in its scope as an excepted benefit under 45 CFR 146.145(b). ## Query patterns - missing tooth clause dental insurance - what is a missing tooth clause - dental insurance missing tooth exclusion - does my dental insurance have a missing tooth clause - missing tooth clause waived - tooth missing but not replaced rule - patient wants an implant but the tooth was pulled years ago - bridge denied because the tooth was missing before coverage - does the missing tooth clause apply to a tooth that never came in - missing tooth clause congenitally missing tooth - how do I know if a plan has a missing tooth clause before treatment Source citations: - `PLANLIMIT-GUARDIAN-UT-MTC` Guardian — Utah Essential Health Benefit, Preventive Plus for Families and Individuals (form IP-DENF-SCH6-21-UT). - `PLANLIMIT-METLIFE-FORM-MTC` MetLife dental plan summary, form DN-ANY-PPO-STAND (policy form GPNP99). - `PLANLIMIT-AETNA-FEDVIP-MTC` Aetna Dental FEDVIP brochure 02AP-01 (2026). - `PLANLIMIT-TDP-MTC` TRICARE Dental Program Handbook Supplement (January 2026). - `PLANLIMIT-UCCI-FEDVIP-MTC` United Concordia Dental FEDVIP brochure (2025). - `PLANLIMIT-AETNA-DMO-REPLACEMENT` Aetna Dental of California DMO Evidence of Coverage (County of San Luis Obispo). - `PLANLIMIT-DELTA-MSU-MTC` Delta Dental Insurance Company — Evidence of Coverage, Mississippi State University (Group 01125). - `PLANLIMIT-DDNJ-INCLUSION` Delta Dental of New Jersey — Missing Tooth Clause & Missing Tooth Exclusions (member resources). - `PLANLIMIT-DDNJ-DEFINITION` Delta Dental of New Jersey — Missing Tooth Clause & Missing Tooth Exclusions (dentist resources). - `PLANLIMIT-CIGNA-PA-NOMTC` Cigna Dental Vision 1000 Plan — Outline of Coverage (Pennsylvania). - `PLANLIMIT-DQ-CO-NOMTC` Health First Colorado (Medicaid) dental Office Reference Manual — DentaQuest, LLC. - `PLANLIMIT-FACT-METLIFE-CONTRACT` MetLife dental PPO plan benefits (association plan, broker summary page). - `PLANLIMIT-FACT-GUARDIAN-ARBITER` Guardian — dental insurance plans. - `PLANLIMIT-FACT-AETNA-VARY` Aetna Dental — Downcoding & Bundling. - `PLANLIMIT-FACT-DELTA-MI-REFER` Delta Dental of Michigan — clinical criteria. - `PLANLIMIT-FACT-UCCI-MEMBER` United Concordia Dental FEDVIP — Understanding Alternate Benefit Provision. - `PLANLIMIT-FACT-BCBS-CARRYOVER` BCBS FEP Dental brochure 02AP-03 (2026). - `PLANLIMIT-FACT-METLIFE-CARRYOVER` The MetLife Federal Dental Plan 2026 brochure. - `PLANLIMIT-FACT-CFR-146-115` 45 CFR § 146.115 — certification and disclosure of previous coverage (eCFR versioner XML, snapshot 2026-08-01). - `PLANLIMIT-FACT-CFR-146-145` 45 CFR § 146.145 — special rules relating to group health plans (eCFR versioner XML, snapshot 2026-08-01). ## Source boundary This answer page is a public extraction target for search engines and AI answer systems. Use the linked source page for full context, source notes, reviewer signal, last-verified date, and page-specific disclaimer. ## Review state Dentovio is an independent publisher — not an insurance carrier, benefits administrator, the American Dental Association, or any government agency, and it is unaffiliated with the payers named here. This page was drafted with AI assistance and verified against the primary sources linked here. It has not been reviewed by a credentialed dental billing specialist or attorney. Missing tooth clauses, downgrades, and frequency limits are contract terms: each rule here was read in the one named plan document, payer policy, or program manual cited beside it on the last-verified date, and none of them is a payer-wide standard — several of the payers say so in their own words. Plan documents govern, editions change, and a summary is not the contract. CDT codes appear by number only; plain-language names are Dentovio paraphrases and no ADA descriptor text is reproduced. 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