Caries Detection Techniques (028)

Number: 028
(Update)

Subject: Caries Detection Techniques

Date: July 23, 2014

Important Note

This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made these decisions 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

We consider the use of lasers and other adjunctive caries detection techniques or tools to be inclusive to an oral evaluation. The use of these tools and/or techniques is not essential to determine or confirm the presence of occlusal, buccal or lingual caries, and can provide false positive results. We consider radiographic interpretation and clinical examination the gold standard for determining the presence of carious lesions.

Background

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

D0120 -- Periodic oral evaluation - established patient
D0140 -- Limited oral evaluation - problem focused
D0150 -- Comprehensive oral evaluation - new or established patient
D0160 -- Detailed and extensive oral evaluation - problem focused, by report

Revision Dates

Original: November 22, 2005

Updated: November 28, 2007; February 24, 2009; May 21, 2012; August 12, 2013; June 9, 2014
Revised: November 20, 2006; March 29, 2010; March 14, 2011

The above policy is based on the following references:

1American Dental Association. CDT 2014Dental Procedure Codes: 5-6.*

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.

4Barberia E, Maroto M, Arenas M, Cardoso Silva C. A clinical study of caries diagnosis with a laser fluorescence system. J Am Dent Assoc 2008; 139 (5), 572-579.

*Copyright 2013 American Dental Association. All rights reserved.

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.

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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.
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