Blue Cross Blue Shield FEP Dental
Class B Intermediate

D5410 Adjust complete denture – maxillary - Limit 1 per year beginning 6 months after the initial installation

D5411 Adjust complete denture – mandibular - Limit 1 per year beginning 6 months after the initial installation

D5421 Adjust partial denture – maxillary - Limit 1 per year beginning 6 months after the initial installation

D5422 Adjust partial denture – mandibular - Limit 1 per year beginning 6 months after the initial installation

D5511 Repair broken complete denture base mandibular - Limit 1 per year beginning 6 months after the initial installation

D5512 Repair broken complete denture base, maxillary - Limit 1 per year beginning 6 months after the initial installation

D5520 Replace missing or broken teeth – complete denture (each tooth) - Limit 1 per year beginning 6 months after the initial installation

D5611 Repair resin denture base mandibular - Limit 1 per year beginning 6 months after the initial installation

D5612 Repair resin partial denture base, maxillary - Limit 1 per year beginning 6 months after the initial installation

D5621 Repair cast framework, mandibular - Limit 1 per year beginning 6 months after the initial installation

D5622 Repair cast partial framework, maxillary - Limit 1 per year beginning 6 months after the initial installation

D5630 Repair or replace broken retentive/clasping materials per tooth - Limit 1 per year beginning 6 months after the initial installation

D5640 Replace broken teeth – per tooth - Limit 1 per year beginning 6 months after the initial installation

D5650 Add tooth to existing partial denture - Limit 1 per year beginning 6 months after the initial installation

D5660 Add clasp to existing partial denture - Limit 1 per year beginning 6 months after the initial installation

D5670 Replace all teeth and acrylic on cast metal framework, maxillary – Limit 2 every 24 months beginning 6 months after the initial installation

D5671 Replace all teeth and acrylic on cast metal framework, mandibular – Limit 2 every 24 months beginning 6 months after the initial installation

D5710 Rebase complete maxillary denture – Limit 1 every 36 months beginning 6 months after the initial installation

D5711 Rebase complete mandibular denture – Limit 1 every 36 months beginning 6 months after the initial installation

D5720 Rebase maxillary partial denture – Limit 1 every 36 months beginning 6 months after the initial installation

D5721 Rebase mandibular partial denture - Limit 1 every 36 months beginning 6 months after the initial installation

D5725 Rebase hybrid prosthesis – Limit 1 every 36 months beginning 6 months after the initial installation

D5730 Reline complete maxillary denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation

D5731 Reline complete mandibular denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation

D5740 Reline maxillary partial denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation

D5741 Reline mandibular partial denture (direct) – Limit 1 every 36 months beginning 6 months after the initial installation

D5750 Reline complete maxillary denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation

D5751 Reline complete mandibular denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation

D5760 Reline maxillary partial denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation

D5761 Reline mandibular partial denture (indirect) – Limit 1 every 36 months beginning 6 months after the initial installation

D5765 Soft liner for complete or partial removable denture – indirect – Limit 1 every 36 months beginning 6 months after the initial installation.

D5850 Tissue conditioning (maxillary)

D5851 Tissue conditioning (mandibular)

D6096 Remove broken implant retaining screw – Limit 1 every 60 months

D6930 Re-cement or re-bond fixed partial denture - Limit 1 per bridge beginning 6 months after the initial installation

D6980 Fixed partial denture repair, by report

D9120 Fixed partial denture sectioning - 1 per 60 Months

Class B Prosthodontic Services Notes:

• For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the cementation date. The completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, the dentist who fabricated the denture may be reimbursed for the service after insertion by another dentist (e.g., oral surgeon).
   
• Tissue conditioning is considered inclusive when performed on the same day as the delivery of a denture or a reline/rebase.