Full-Mouth Debridement To Enable Comprehensive Evaluation and Diagnosis (008)

Number: 008
(Updated)

Subject: Full-Mouth Debridement To Enable Comprehensive Evaluation and Diagnosis

Reviewed: August 12, 2013

Important Note

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:

  • 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
  • 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, 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.

Policy

This procedure may be considered for coverage under certain dental plans. Treatment must be determined to be necessary, appropriate and consistent with the guidelines established by the American Academy of Periodontology (AAP) and the American Dental Association (ADA).

Background

The AAP defines active therapy as “surgical and/or nonsurgical periodontal therapies exclusive of full-mouth debridement.” Full-mouth debridement is intended for patients with excessive plaque and calculus that interferes with the ability of the dental professional to perform a comprehensive oral evaluation.1 Full-mouth debridement is considered a preliminary, non-therapeutic procedure. It is indicated in rare situations when the patient has not had a dental visit for a prolonged period of time.

Codes1

D4355 - Full-mouth debridement to enable comprehensive evaluation and diagnosis

Revision Dates

Original policy: April 12, 2005
Updated: March 15, 2006; May 24, 2010; April 25, 2011; May 21, 2012;August 12,2013
Revised: March 12, 2007; April 29, 2008; March 30, 2009

The above policy is based on the following references:

1 American Dental Association. Current dental terminology, CDT 2013; 35.*
2 American Dental Association. Dental practice parameters: Gingival inflammation with loss of connective tissue attachment (Periodontitis); 1994.
3 American Academy of Periodontology. Parameter on comprehensive periodontal examination. J Periodontol. May 2000; 5 Suppl: 847-848.
4 American Academy of Periodontology. Position paper: guidelines for periodontal therapy. J Periodontol. 2001; 72: 1624-1628.

*Current Dental Terminology. Copyright 2012 American Dental Association. All rights reserved.

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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  • Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.
  • While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your 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 or the Federal government.
  • Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.
  • Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.
  • Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.
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