Complete dentures (D5110 / D5120) — payer documentation requirements

Aetna's public claim-documentation guidelines carry no complete- or partial-denture entry: the denture codes do not appear, no replacement interval is published, and Aetna states that frequency limits and missing-tooth provisions are plan terms.

• •D5110, D5120, D5213 and D5214 do not appear anywhere in the guidelines; the only removable-prosthesis row is D5875, which calls for a narrative
• •The guidelines state that all claims are subject to plan provisions which may or may not include an alternate benefit provision, a missing-but-unreplaced provision, and frequency limitations — so there is no Aetna-wide denture interval to quote
• •The document that would carry plan frequency limits, Aetna's Dental Office Guide, sits behind the provider login and is not publicly citable
• •Prosthodontic services may not be covered for teeth with a poor or questionable prognosis from advanced periodontal disease, a crown-root ratio under 50%, untreated periapical pathology, poor restorability, or carious destruction of the clinical crown at or below the osseous crest

Frequency / timing: None published. Aetna states frequency limitations are plan provisions that may or may not apply.

Verified 2026-08-30 · read from

Aetna Dental and Oral Surgery Claim Documentation Guidelines, last updated July 21, 2025 (PDF)

Cigna's 2026 guidelines contain no conventional complete- or partial-denture policy — only immediate and interim dentures — and neither carries a frequency interval or a radiograph requirement.

• •The only removable-prosthodontic policies are immediate dentures (RPROS-01) and interim dentures (RPROS-02); there is no conventional complete- or partial-denture policy in either the DPPO or the DHMO guidelines
• •Neither policy states a frequency interval or a radiograph requirement; each closes by noting that the specific benefit plan's missing-tooth or frequency limitations may apply
• •For removable partial dentures the requirement is documentary: indicate whether this is an initial placement or a replacement and, for a replacement, give the date of prior placement, the type of prosthesis, and the specific rationale
• •Under prosthodontic services only the overdenture codes sit on the list of codes that require X-ray submission; conventional complete and partial dentures are not on it
• •There is no payment and no charge to the patient for recementation, adjustment, repair, or a reline or rebase performed on a prosthesis completed or delivered within 180 days by the same dentist or dental office

Frequency / timing: None published in the clinical guidelines. The office reference guide sets a 180-day same-office no-payment window for relines, rebases, adjustments and repairs.

Verified 2026-08-30 · read from

Cigna Dental Clinical Coverage Determination Guidelines — DPPO, May 2026 re-issue, form 999493 05/26 (PDF)Cigna Dental PPO dental office reference guide, form 988135 12/25 (PDF; also via CignaforHCP.com › Resources › Reference Guides)

Delta Dental Ins.'s removable-prosthodontics section is general guidelines only — no denture codes, no frequency interval — and its denial conditions are clinical: uncontrolled periodontal disease, hopeless abutments, unresolved periapical pathology, or vertical-dimension cases.

• •The removable-prosthodontics section carries general guidelines only: no denture codes, no replacement interval, and no extraction-date or arch field appear in it
• •Benefits for prosthodontic procedures may not be allowed where untreated or uncontrolled periodontal disease is present, abutment teeth have a poor to hopeless prognosis, periapical pathology is unresolved, or the services are meant to treat TMJ by increasing vertical dimension or restoring occlusion
• •Where a procedure fails the criteria, Delta Dental may instead provide a benefit for an alternate service consistent with the patient's clinical presentation

Verified 2026-08-30 · read from

Delta Dental Ins. Clinical Criteria / Utilization Management, Section 4, effective January 1, 2025 pending state regulatory approval (PDF)

Arkansas Medicaid covers removable complete and partial dentures at one per arch per lifetime — conventional or immediate alike — in both the children's and the adult programs.

Scope: Arkansas Medicaid only — Delta Dental Smiles for Kids (through age 20) and adult Delta Dental Smiles (21 and over).

• •One removable complete denture and one removable partial denture are covered once per arch in a lifetime, for children through age 20 and for adults 21 and over — the unit is the arch, not the patient
• •Conventional and immediate dentures share the same lifetime slot, so delivering an immediate denture consumes that arch's lifetime benefit
• •Where Medicaid has already paid for one of these services, the member may not be able to receive it under this plan; changing Arkansas Medicaid dental plans does not reset the clock
• •The adult program's $500 annual maximum does not apply to dentures or to extractions
• •A partial denture is a covered service where the member is missing two or more posterior teeth on at least one side, or is missing an anterior tooth; third molars do not qualify for replacement
• •Immediate complete dentures require preauthorization and a signed consent form, with all posterior teeth distal to the canines extracted at least six weeks beforehand; immediate partials do not require preauthorization
• •Necessary adjustments and exams for the first six months after delivery are included in the denture, not separately covered

Frequency / timing: One complete and one partial denture per arch per lifetime, conventional or immediate.

Verified 2026-08-30 · read from

Delta Dental Smiles Provider Manual V12, effective December 1, 2023 — §§7.1.6 and 7.3.5, removable prosthetic services (PDF)

No current MetLife criteria are publicly readable, so the defensible route is pre-treatment review or the patient's certificate; the one readable MetLife plan document sets ten years, not five, for replacing a denture.

Scope: One employer's MetLife PDP Plus summary plan description, republished by the plan sponsor — MetLife-authored plan language, but one group's contract, not a MetLife policy manual.

• •MetLife's provider criteria sit behind a single-sign-on wall — the provider portal returns an authentication redirect even for robots.txt and a 401 for its sitemap — so no current MetLife documentation criteria can be read without credentials
• •The publicly readable MetLife plan document recommends pre-treatment review to confirm coverage; that, or the patient's certificate, is the only reliable way to get a MetLife frequency answer
• •In that plan an existing denture, fixed denture, or partial must be over ten years old before a replacement is covered, unless it was damaged beyond repair by injury while in the mouth
• •The same plan applies its least-expensive-alternate-treatment provision to dentures, and covers implants and their treatment once every ten years for members age 16 and over

Frequency / timing: Plan-specific. Ten years in the one MetLife-authored plan document Dentovio could read; no payer-wide MetLife interval is publicly published.

Verified 2026-08-30 · read from

MetLife PDP Plus plan language republished by a plan sponsor — Lumen Technologies Dental Plan summary plan description, effective January 1, 2026, p. 14 (PDF)MetLife dental provider portal (current criteria; single sign-on required)

United Concordia's public Medicaid guide runs three different denture clocks — five years for members under 21, a lifetime limit for adults, and a two-year reline cycle with the first six months bundled into the denture.

Scope: United Concordia's public DE/PA/WV Medical Assistance guide. These are state Medicaid program rules, not commercial PPO terms.

• •For individuals under age 21, complete dentures are limited to one per denture arch per five years regardless of procedure code
• •The adult Medicaid benefit runs on a lifetime limit — one upper arch and one lower arch, full or partial — rather than a five-year clock
• •Replacement of a removable prosthesis is covered only where the existing prosthesis was inserted within the stated time limitation and satisfactory evidence is presented that it cannot be made serviceable
• •The fee for a denture or partial denture includes all necessary adjustments and relines during the six-month period following insertion
• •For members 21 and over, relining is limited to one per arch every two years regardless of procedure code, full or partial; a rebase runs on a five-year cycle

Frequency / timing: Under 21: one per arch per five years. Adults: a lifetime limit per arch. Relines: one per arch every two years, with the first six months bundled.

Verified 2026-08-30 · read from

United Concordia Dental Reference Guide — Medical Assistance DE, PA, WV, Volume 2026 Issue 1 (PDF)

Guardian's clinical guidelines contain no removable-prosthodontics section at all; the denture rules live in the network dentist manual as a five-or-ten-year binary set by the employer's plan design.

Scope: The interval and bundling rules come from Guardian's DentalGuard Preferred network dentist manual, not from its clinical guidelines.

• •The public 2026 clinical guidelines contain no removable-prosthodontics section; Dentovio read all 13 pages on 2026-08-30 to confirm that absence
• •The network dentist manual's standard plan limitations state that replacement of crowns, bridges, dentures, inlays and onlays, laminate veneers, and post and cores is limited to either five or ten years — a binary set by the employer's plan design, not a five-to-ten-year range, and introduced as one of the more common limitations rather than a universal rule
• •A denture rebase or reline within 12 months of a complete, partial or interim denture is inclusive of that denture
• •A denture adjustment within six months of a reline is inclusive of the reline

Frequency / timing: Either five or ten years by employer plan design, per the network dentist manual — no interval appears in the clinical guidelines.

Verified 2026-08-30 · read from

Guardian DentalGuard Preferred network dentist manual, stamped 08.25.2025 (PDF)Guardian Dental Clinical Guidelines 2026, updated August 12, 2026 (PDF)

Colorado Medicaid covers a complete denture once every seven years for adults and five for children, with prior authorization built on a treatment plan and radiographs — and it declines the denture where eight or more posterior teeth remain in occlusion.

Scope: DentaQuest's Colorado Health First Medicaid program (adult and child subgroups). The manual updates quarterly with a change log.

• •A complete denture is covered once every seven years for adults, five years for children, and the benefit includes the first six months of relines
• •Complete, immediate and partial dentures require prior authorization
• •The prior-authorization packet is a treatment plan plus appropriate radiographs clearly showing the adjacent and opposing teeth — bitewings, periapicals or panoramic images
• •The denture is not covered where eight or more posterior teeth remain in occlusion
• •Abutment teeth must be at least 50% supported in bone and periodontal health must be AAP Type I or II
• •Relines are reimbursed once per denture every four years and are included in the denture fee for the first six months after insertion; the reline codes had utilization-management review removed effective March 1, 2025
• •Effective July 1, 2026 Colorado adult dental carries a $3,000 state-fiscal-year benefit limit, but emergency treatment and dentures are not subject to it

Frequency / timing: One complete denture every seven years for adults, five for children; relines once per denture every four years.

Verified 2026-08-30 · read from

DentaQuest Colorado Health First Medicaid Office Reference Manual, updated July 1, 2026 (PDF)

MCNA's Texas children's program prior-authorizes complete dentures with x-rays and documented medical necessity, and runs relines on a rolling-year clock keyed to the denture placement date.

Scope: MCNA's Texas book. Medicaid and CHIP criteria live in different chapters of the same manual and are not interchangeable.

• •The complete-denture codes require prior authorization, x-rays and documentation of medical necessity submitted with the authorization request
• •A reline is denied when performed within one rolling year of the denture placement codes, by any provider
• •Relines are limited to once every three rolling years by the same provider, and are documented with the claim rather than through a prior authorization
• •On the CHIP side, relines are reimbursed once per denture every 36 months, and adjustments within six months of initial placement are covered under the initial payment
• •A denture is an initial placement only if the member has never worn a prosthesis — the CHIP criteria state this refers to the member's entire lifetime, not only the time under one provider

Frequency / timing: Relines: denied within one rolling year of placement, then once every three rolling years by the same provider (36 months on the CHIP side).

Verified 2026-08-30 · read from

MCNA Texas Medicaid and CHIP Provider Manual v1.31, effective March 1, 2026