Skip to main content

Dental clinical policy bulletins

028 - Caries Detection Techniques

 

044 - Diagnostic tools and/or devices

 

045 - Cancer Screening Adjuncts

 

048 - Dental Radiographic Examinations

032 - Preventive Resin Restorations

 

033 - Space Maintenance in Primary Dentition - Loss of Primary Incisors

001 - Bone Graft Policy

001 - Bone Graft Policy

 

002 - Guided Tissue Regeneration

 

003 - Local Delivery of Antimicrobial Agents (LDAs) 

 

004 - Clinical Crown Lengthening

 

005 - Biologic Materials To Aid in Osseous Tissue Regeneration

 

007 - Soft Tissue Graft Procedures

 

008 - Full Mouth Debridement To Enable Comprehensive Evaluation and Diagnosis

 

009 - Immediate Surgical Placement of Implant Body with Soft Tissue Grafting, Osseous Grafting and Guided Tissue Regeneration

 

012 - Periodontal Pocket Reduction Surgery

 

013 - Bone Replacement Grafts for Periodontal Surgical Procedures

 

040 - Initial Periodontal Therapy Reevaluation

 

041 - Scaling and Root Planing

 

042 - Scaling in Presence of Generalized Moderate or Severe Gingival Inflammation

036 - Treatment of Peri-implantitis

 

009 - Immediate Surgical Placement of Implant Body with Soft Tissue Grafting, Osseous Grafting and Guided Tissue Regeneration

001 - Bone Graft Policy

 

006 - Brush Biopsy -- Transepithelial Sample Collection

 

009 - Immediate Surgical Placement of Implant Body with Soft Tissue Grafting, Osseous Grafting and Guided Tissue Regeneration

 

010 - Alveoloplasty -- Surgical Preparation of Ridge in Preparation for a Prosthesis

 

011 - Frenulectomy (Frenectomy, Frenotomy) or Frenuloplasty

 

015 - Criteria for the Removal of Impacted Teeth

 

031 - Odontogenic Cysts

 

047 - Infiltration of Sustained Release Therapeutic Drug

034 - Temporary Anchorage Devices in Orthodontics

016 - Deep Sedation/General Anesthesia and I.V. Sedation for Oral and Maxillofacial Surgery and Dental Services

 

029 - Occlusal Adjustment

 

046 - Temporomandibular Joint Dysfunction – Non-invasive Physical Therapies

 

047 - Infiltration of Sustained Release Therapeutic Drug

039 - Medically Necessary Orthodontia related to the Pediatric Dental Essential Benefit in the Affordable Care Act (ACA)

 

037 - Bone and Tendon Graft Substitutes and Adjuncts

 

018 - Obstructive Sleep Apnea

 

019 - Temporomandibular Joint Syndrome (TMJ) and Temporomandibular Disorders (TMD)

 

020 - Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans

 

021 - Speech Therapy

 

022 - Electrical Stimulations (Salitron System) for Xerostomia

 

023 - Therabite Jaw Motion Rehabilitation System

 

024 - Speech Generating Devices

 

025 - Distraction Osteogenesis for Craniofacial Skeletal Deformities

 

026 - Facial Prostheses, External

 

027 - Intraoral Appliances for Headaches

 

046 - Temporomandibular Joint Dysfunction – Non-invasive Physical Therapies

038 - Resin Infiltration of Incipient Smooth Surface Lesions

 

043 - Core buildup

 

049 - Prefabricated porcelain/ceramic crown – permanent tooth

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

Health benefits and health insurance plans contain exclusions and limitations.