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Health Coverage
Clinical Policy Bulletins
Dental - Clinical Policy Bulletins
Number: 030 Subject: Space Maintenance (Passive Appliances) 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 eligible, 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 placement of space maintainers (passive appliance, exclusive of teeth) for maxillary anterior teeth to be not medically necessary. Space maintainers are considered necessary when primary molars are lost prematurely.Background The most confident way to prevent the loss of space in dental arches is through the use of space maintainer appliances. The use of space maintainers may prevent or reduce the severity of a developing malocclusion. They are passive appliances designed to prevent tooth movement. They hold teeth in position until the permanent teeth erupt.1,2A space maintainer is made of stainless steel and/or plastic. It can be removable or cemented in placed (fixed space maintainer).Premature loss of primary incisors does not require the placement of appliances for space maintenance because no forward movement of the adjacent teeth is expected when the canines have already erupted. Not every tooth that is lost too early requires a space maintainer. If one of the four upper front teeth is lost early, the space will be maintained on its own until the permanent tooth comes in.3 Premature loss of the primary molar teeth, especially second molars, often requires space maintenance to counteract the forward drift of the adjacent permanent molar. Codes1 D1510 -- space maintainer -- fixed -- unilateralD1515 -- space maintainer -- fixed -- bilateral D1520 -- space maintainer -- removable -- unilateral D1525 -- space maintainer -- removable -- bilateral D1550 -- recementation of space maintainer D1555 -- removal of fixed space maintainer Revision 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: 10.*2http://www.simplestepsdental.com/SS/ihtSS/r.WSIHW000/st.32578/t.32580/pr.3.html 3Rapp R, Demoriz I. A new design for space maintainers replacing prematurely lost first primary molars. Pediatric Dentistry. 1983 Jun; 5(2): 131-4. 4Brothwell DJ. Guidelines on the use of space maintainers following premature loss of primary teeth. J Can Dent Assoc. 1997 Nov; 63(10):753,757-60,764-6.
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. Copyright 2001-2007 Aetna Inc. |
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