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Health Coverage
Clinical Policy Bulletins
Dental - Clinical Policy Bulletins Number: 028 (Updated) Subject: Laser Fluorescence Caries Detection 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 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 the use of lasers for detection of clinical caries to be an adjunctive procedure that is part of an appropriate oral evaluation. Use of lasers is not essential to determine or confirm the presence of occlusal, buccal or lingual caries and can provide false positive results. Aetna considers radiographic interpretation and clinical examination the gold standard for determining the presence of carious lesions.Background Infrared laser fluorescence (ILF) involves use of a laser to compare reflection wavelengths against a known baseline wavelength. The laser is aimed at one of the healthy enamel surfaces to provide a benchmark reading. This reading is then compared to readings of areas that are suspected to be carious. As the laser pulses into grooves, fissures and cracks, it reflects fluorescent light of a specific wavelength. A receptor connected to an acoustic signal measures and electronically evaluates this light. A reading other than the healthy baseline value would indicate that the area should be monitored and treated accordingly.There are limited numbers of longitudinal and cross-sectional studies surrounding the use and effectiveness of this method for caries detection. There are various reported levels of specificity, sensitivity, receiving optical characteristics (ROC), accuracy and correlation with the dental exam using conventional diagnostic aids such as radiographs, explorer/probe and direct visualization. Some studies have indicated that the use of ILF has yielded a “reasonable level of accuracy (sensitivity and specificity)” compared to appropriate in vitro gold standards. Clinical trials are currently funded and underway to evaluate the efficacy of DIAGNOdent and other emerging technologies. Laser fluorescence caries detection technology may be marketed as qualitative light induced fluorescence (QLF), fiber optic transillumination (FOTI), infrared laser fluorescence (ILF) and digital imaging fiber-optic transillumination (DIFOTI). Code1 D0425 -- Caries Susceptibility TestsRevision 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.*2Berg Joel H. New technologies in pediatric dentistry: dental caries detection and caries management by risk assessment. Contemporary Esthetics. August 2005; Vol. 9 (8): 58. 3Bader JD, Shugars DA. A systematic review of the performance of a laser fluorescence device for detecting caries. J Am Dent Assoc 2004 Oct; 135(10):1413-1426.
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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