Intraoral Prostheses - (0584)

Cigna covers maxillary obturators and mandibular resection/palatal augmentation prostheses (CPT 21079–21082) as medically necessary only for functional impairment from congenital/developmental defects, accidental tooth loss occurring after coverage if replaced within 12 months, tooth loss from oral cancer (replacement within 24 months while covered), or head/neck cancer requiring tumor removal or reconstruction, and excludes other indications (e.g., non‑cancer decay) or use with non‑covered dental implants. Coverage requires plan‑specific benefit language, appropriate CPT/diagnosis coding and documentation (medical/dental records, operative notes, date/nature of injury), and strict adherence to timing rules (accident ≤12 months, oral‑cancer ≤24 months); chewing injuries are not considered accidental.

"Maxillary prostheses (CPT code 21079, 21080) and prostheses used in mandibular resection (CPT code 21081, 21082) are considered medically necessary when ANY of the following criteria are met:"