Subject: Alveoloplasty -- surgical preparation of ridge in preparation for a prosthesis
Date: April 30, 2013
This Clinical Policy Bulletin expresses our determination of whether certain services or supplies are medically necessary. We have reached these conclusions based on a review of currently available clinical information including:
Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee 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 we consider 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.
PolicyAetna 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.
Original policy: November 22, 2005
Updated: November 28, 2007; December 29, 2008; December 21, 2009; February 28, 2011; April 9, 2012; April 30, 2013
The above policy is based on the following references:
1American Dental Association. Current dental terminology, CDT 2013: 66.*
2American Medical Association. Current procedural terminology, CPT-2010: 153.**
3Kruger, Gustav O. Complicated Exodontics, Chapter 5, Preprosthetic Surgery. Chapter 8, Textbook of Oral Surgery. St. Louis: C V Mosby Company; 2002: 71-76: 111-119.
4Archer, W. Harry. Oral Surgery for Dental Prostheses, Chapter 3, Oral and Maxillofacial Surgery. Carlsbad: W.B. Saunders; 1975:179-182.
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.
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