Subject: Treatment of Peri-implantitis
Date: July 23, 2014
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:
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.
Despite large numbers of publications available regarding peri-implantitis treatments, there are no long term studies which indicate that the uses of osseous contouring, placement of barriers or bone grafts are superior to flap reflection with debridement. Therefore, Aetna considers flap reflection with debridement as the accepted clinical protocol for peri-implantitis treatment.
Peri-implantitis is defined as an inflammatory process affecting the tissues around an osseointergrated implant in function resulting in loss of supporting bone. Clinical signs are deep probing depth (> 5 mm) bleeding and/or suppuration on probing. Loss of supporting bone usually forms a circumferential crater defect. Large scale studies detected peri-implantitis in 12% of implants in function for at least 5 years and 43% of implants in function for 9-14 years. Biofilms consist predominately of gram negative anaerobes and are similar to those found in chronic periodontits, but bone loss is more rapid in peri-implantitis. Risk factors include poor oral hygiene, smoking, diabetes and a history of chronic periodontitis.
D4241 - Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant
D6101 - Debridement of a peri-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure
D6102 - Debridement and osseous contouring of a peri-implant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure
D6103 - Bone graft for repair of peri-implant defect - not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration
D6104 - Bone graft at time of implant placement
Original policy: September 10, 2012
Update: September 23, 2013; July 23 , 2014
The above policy is based on the following references:1 American Dental Association. CDT 2014 Dental Procedure Codes: 32, 56.*
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.