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 Aetna considers this surgical procedure to be dental-in-nature (DIN) oral surgery. Coverage may be available for DIN oral surgical procedures under either medical or dental plans.

Background

Alveoloplasty, in conjunction with extractions, is a surgical procedure that recontours the alveolar bone and is usually performed to prepare the alveolar ridge for a dental prosthesis. This procedure may require the elevation of a mucoperiosteal flap to allow access to the alveolar cortical bone of the maxilla (upper jaw) or mandible (lower jaw). Protuberant or excessive cortical bone not removed during the extraction procedure would be removed during an alveoloplasty procedure with additional surgical instrumentation. This procedure is usually reported separately from the removal of teeth within the same quadrant on the same date of service.

Alveoloplasty, not in conjunction with extraction of teeth, is defined as the removal of bone within a quadrant and is usually performed to accommodate the placement of a dental prosthesis. This procedure is the same procedure as that noted above, except that there is no report of tooth removal on the same date of service. The surgical procedure involves mucoperiosteal flap elevation and removal of protuberant bone that has been determined to have an adverse effect on stability and comfort for a future dental prosthesis. A quadrant, as defined in CDT 2007-2008, is one of the four equal sections into which the dental arches can be divided. A quadrant begins at the midline of each arch and extends distally to the last tooth.¹ Each quadrant includes up to eight teeth or tooth spaces.

Codes

Revision Dates

The above policy is based on the following references: