Fixed partial dentures / bridges (D6205–D6794) — payer documentation requirements

For fixed prosthodontics Aetna asks for full-mouth or panoramic pre-operative radiographs — not a periapical — plus extraction dates, the prior prosthetic placement date and rationale, and the numbers of all missing teeth.

• •The fixed-prosthodontics row asks for current dated full-mouth pre-operative radiographs and/or a panoramic radiograph, extraction dates of the teeth being replaced, the date of any prior prosthetic placement with the rationale for replacement, and the numbers of all missing teeth
• •Aetna's missing-tooth concept is a plan provision, not a clinical criterion: claims are subject to plan provisions which may or may not include an alternate benefit provision, a missing-but-unreplaced provision, and frequency limitations
• •No bridge replacement interval appears in any public Aetna document; the frequency source is the login-gated Dental Office Guide
• •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

Verified 2026-08-30 · read from

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

Cigna allows replacement of an unserviceable bridge and states no replacement interval; its published alternate-benefit example reimburses a fixed bridge at the partial-denture fee where a partial would restore the teeth satisfactorily.

• •Replacement of an existing bridge is allowable where it is unserviceable due to conditions such as open margins, recurrent decay, or restorative-material failure
• •None of the three fixed-prosthodontic policies states a replacement interval; each says a plan frequency limitation may apply
• •The fixed-prosthodontic code block is on the list of codes requiring X-ray submission, but no film type, date, or field of view is specified
• •The attachment table asks whether this is an initial placement of missing teeth or a replacement and, for a replacement, the date of prior placement, the type of prosthesis being replaced, and the specific rationale
• •Cigna's published alternate-benefit example runs bridge to partial denture: where a removable partial denture can restore the missing teeth satisfactorily and the dentist submits for a fixed bridge, the plan reimburses at the contract fee for the partial denture

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)

For bridge abutment crowns Delta Dental Ins. requires a pre-operative periapical taken within one year of the preparation — a panoramic is not a substitute — and declines a posterior bridge plus a removable partial where three or more teeth are missing in contralateral quadrants.

• •A pre-operative periapical radiograph showing the current endodontic and periodontal state of the tooth, taken within one year of the crown preparation, is required for bridge abutment crowns; a panoramic radiograph is not a substitute
• •Duplicate radiographs or image copies of diagnostic quality, including paper copies of digitized images, are acceptable
• •Placement of a posterior fixed partial denture and a removable partial denture will not be considered for benefit where the total number of missing teeth in contralateral quadrants is three or more and the occlusion can be adequately restored with the removable prosthesis
• •Teeth with uncontrolled or untreated periodontal disease evidenced by extensive bone loss typically have a compromised long-term prognosis and will not be considered for restorative services

Verified 2026-08-30 · read from

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

United Concordia's published bridge criteria are about abutment support, not intervals: retainer teeth must have no more than 50% bone loss and no furcation involvement, and no missing-tooth clause appears anywhere in the guide.

Scope: United Concordia's public DE/PA/WV Medical Assistance guide. The commercial PPO reference guides that would carry commercial bridge rules are behind the Dental Hub login.

• •Retainer teeth must have no more than 50% bone loss and no furcation involvement
• •The review criteria direct the reviewer to consider a partial denture where teeth are missing in both quadrants of the same arch
• •In the children's Medicaid schedule a pontic and a retainer are each covered once in five years
• •No missing-tooth clause and no date-of-extraction requirement appear anywhere in the 137-page guide; Dentovio searched it on 2026-08-30 to confirm that absence

Verified 2026-08-30 · read from

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

Guardian's bridge gate is prior tooth loss, not an interval: the tooth must have been extracted while the member was insured with the plan, with the prior carrier's explanation of benefits required after a group transfer.

• •Benefit may only be allowed when necessary to replace a tooth or teeth extracted while the member is insured with the plan; where a prior plan paid extraction benefits after a group transfer, a copy of the explanation of benefits reflecting that coverage is required
• •Submissions must include current diagnostic pre-operative periapical and/or bitewing x-rays, patient chart notes and any relevant intraoral photographs; a pre-treatment estimate is recommended
• •The benefit allowance for a fixed partial denture may be limited to the corresponding removable partial denture allowance where the patient has two or more bilaterally missing posterior teeth, as the least expensive alternate treatment
• •Where a less expensive alternate benefit is given, the network dentist manual states the contracted dentist may balance-bill the patient up to the fee schedule amount for the service actually rendered
• •No replacement interval appears in the clinical guidelines; the network dentist manual's five-or-ten-year limitation covers bridges along with crowns, dentures, inlays and onlays, veneers, and post and cores, by employer plan design

Verified 2026-08-30 · read from

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

Two DentaQuest state programs answer the bridge question differently, and both answers are absences: Colorado's manual has no fixed-partial-denture criteria at all, and Virginia excludes bridges for adults outright.

Scope: Two state programs DentaQuest administers. Each state's criteria differ, and the code-level authority is that state's own office reference manual.

• •Colorado Medicaid: the office reference manual has no fixed-partial-denture criteria section and no bridge prior-authorization entry; the only fixed-bridge code in the covered lists is the repair code
• •Virginia (Cardinal Care Smiles): bridges are not a covered benefit for adults age 21 and over — stated three times in a state bulletin issued specifically to correct an earlier memo that said they were
• •Virginia's bulletin points code-level questions at the Cardinal Care Smiles office reference manual, and notes that a managed care plan may use different guidelines than fee-for-service Medicaid

Verified 2026-08-30 · read from

DentaQuest Colorado Health First Medicaid Office Reference Manual, updated July 1, 2026 (PDF)Virginia DMAS Medicaid bulletin — Clarification for adults enrolled in dental Medicaid, last updated 09/05/2024

MCNA's Texas children's program prior-authorizes bridges against three stated criteria — an abutment that needs a crown, a space a removable partial cannot fill, and prevention of drifting — with a periapical for every tooth involved.

Scope: MCNA's Texas children's Medicaid book, birth through age 20.

• •Fixed prosthodontic codes require prior authorization, and periapical radiographs are required for each tooth involved in the request
• •The dental director's criteria include that at least one abutment tooth requires a crown
• •The space cannot be filled with a removable partial denture
• •The purpose is to prevent the drifting of teeth in all dimensions
• •The pontic and retainer codes carry a 16-to-20 age band

Verified 2026-08-30 · read from

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