Clinical Policy Bulletins

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Dental - Clinical Policy Bulletins

Number: 004
(Updated)

Subject: Clinical Crown Lengthening

Reviewed: September 5, 2007

This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary. We have reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical and dental literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians and dentists practicing in relevant clinical areas, and other relevant factors). We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

Each benefits plan defines which services are covered, which are excluded and which are subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if there are any exclusions or other benefits limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.

Policy

Clinical crown lengthening is generally categorized as a dental procedure used to facilitate placement of a restoration on a tooth with little or no tooth structure exposed to the oral cavity. Radiographic evidence of fracture or decay that extends below or near the alveolar crest is the usual clinical indication for necessity of the procedure. Aetna considers clinical crown lengthening in conjunction with osseous surgery for periodontal disease inclusive to the osseous surgery.  

Background

Clinical crown lengthening is a periodontal procedure in which gingival and osseous tissue is removed in order to expose more clinical tooth structure to the oral cavity. Crown lengthening requires reflection of a flap and osseous recontouring. It is performed in a healthy periodontal environment, as opposed to osseous surgery, which is performed in the presence of periodontal disease. If there are adjacent teeth, the flap design may involve a larger surgical area.

In the absence of periodontal disease, a clinical crown lengthening procedure performed on one tooth requires extension of the osseous recontouring to partially include teeth that may be present (contiguous) on either side.

Codes¹

D4249 -- Clinical crown lengthening -- hard tissue

Revision Dates

Original policy:  September 13, 2004
Updated: September 5, 2007
Revised:  December 5, 2005

 The above policy is based on the following references:

¹American Dental Association. Current Dental Terminology, CDT-2007-2008: 23.*

²American Academy of Periodontology. AAP Policy Statement; Surgical Clinical Crown Lengthening, 2003.

*Copyright 2006 American Dental Association. All rights reserved

Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and, therefore, is subject to change.