D6197 - Replace Restor Mat
Replacement of material to close screw access.
- Procedure Code
- D6197
- Category
- Implant Services
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental 2026
- Frequency Limitation
- 1 per tooth/site in a 60-month interval (5 years) (rolling_12_months)
- Age Limitation
- Restricted to patients age 19 or older. Implants are not a benefit for patients under 19 years of age.
Required Claim Attachments & Pre-Submission Checklist
- Post-operative radiograph or surgical operative report
Bill When (Allowable Clinical Criteria)
- Benefits are limited to once every 24 months.
Restrictions & Clinical Exclusions
- Fees for replacement of restorative material to close an access opening of a screw retained implant supported prosthesis when performed by the same dentist/dental office within 6 months placement of the implant prosthesis are not billable to the patient.
- Fees for D6197 are not billable to the patient on the same date of service by same dentist/dental office as D6080 or D6090.
- For benefit purposes, anesthesia is an integral part of the procedures being performed and additional fees are not billable to the patient.
- Benefits are denied, unless the group/individual contract specifies that implant services are a benefit.
- All services and treatment provided remotely via tele-health modalities, be they synchronous or asynchronous, must be performed by a licensed dentist or their supervised staff, acting within the scope of applicable law. Services and treatment delivered virtually are only a benefit when the elements included in the descriptor of the CDT procedure code are completed and only when they meet generally accepted clinical guidelines.
- Fees for repairs to implant prosthesis cannot exceed one-half of the fee for a new appliance, and any excess fee by the same dentist/dental office is not billable to the patient.
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Benefit maximum or frequency limitation exceeded for procedure | Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria. |
ICD-10 Justification & Crosswalk Mappings
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|