Preventive Resin Restorations (032)

Number: 032
(Updated)

Subject: Preventive Resin Restorations

Reviewed: September 10, 2012

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

Aetna considers the placement of a preventive resin restoration (PRR) to be a treatment for caries found in the pits and fissures in a documented moderate to high caries risk patient. Aetna’s policy is that if decay is present on posterior permanent teeth and it extends into the dentin, the restoration is considered a posterior composite. If the decay (active cavitated lesion) does not extend into the dentin, it is considered a preventive resin restoration. The PRR procedure includes placement of a sealant in any radiating non-carious fissures or pits.

Background

The preventive resin restoration (a combination of composites and/or sealants) is a treatment for caries found in the pits and fissures of posterior permanent teeth in a documented moderate to high caries risk patient when the carious lesion is isolated to the enamel. A patient's caries risk assessment may be evaluated and documented by a variety of methods. One such assessment tool can be found at Simple Steps.

An Aetna continuing education course is available for participating providers: Cariology CE Course.

The use of preventive resin restorations is generally governed by the desire to treat small lesions conservatively, and they are usually placed in the nonstress-bearing regions of the dentition.1

Codes2

D1352 -- Preventive resin restoration in a moderate to high caries risk patient - permanent tooth

Revision Dates

Original: December 29, 2008

Updated: December 21, 2009; August 8, 2011; September 10, 2012
Revised: August 23, 2010

The above policy is based on the following references:

1Dorothy D. McComb, B.D.S., M.Sc.D., FRCD(C). NIH Consensus Development Conference on Caries. Copyright 2000 Regents of the University of Michigan. 2003.

2American Dental Association. Current dental terminology, CDT 2011-2012: 12.*

*Copyright 2010 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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