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Health Coverage
Clinical Policy Bulletins
Dental - Clinical Policy Bulletins
Number: 017 Subject: Adjunctive Prediagnostic Test Date:November 28, 2007 Important Note This Clinical Policy Bulletin expresses Aetna's 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 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 the use of any light source used for evaluation or screening of precancerous or cancerous oral lesions (for example, transillumination of tissue) an adjunctive procedure that is part of an appropriate oral evaluation.Background The most definitive, accurate and reliable method for diagnosing oral mucosal lesions is the scalpel biopsy.Currently, devices and instruments are marketed as a means for patients to benefit from improved identification of oral precancerous and early cancerous lesions and possibly prevent the disease through early intervention. This technique involves luminescence of tissue with a light source. ViziLite technology, made by Zila, Inc., is one such device. Although the Code Revision Committee (CRC) of the American Dental Association (ADA) has approved a code for reporting oral cancer screening products, Aetna considers the scalpel biopsy the most definitive, accurate and reliable method for diagnosing oral mucosal lesions. Therefore, the use of any light source for evaluation or screening of precancerous or cancerous oral lesions (transillumination of tissue) would be considered an adjunctive procedure that is part of an appropriate oral evaluation. Code1 D0431 -- Adjunctive prediagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy proceduresRevision Dates Original: November 22, 2005Updated: November 28, 2007 Revised: November 20, 2006 The above policy is based on the following references: 1American Dental Association. Current dental terminology, CDT 2007-2008: 6*2The Oral Cancer Foundation website. Accessed August 13, 2004. http://www.oralcancerfoundation.org. 3Zila Pharmaceuticals website. Accessed November 22, 2005. http://www.zila.com/pages/zila_prof_pharm/index_prof.shtml
Property of Aetna. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This 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 advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change. Copyright 2001-2007 Aetna Inc. |
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