Subject: Clinical Crown Lengthening
Reviewed: March 17, 2015
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 refer to 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.
Clinical crown lengthening is generally categorized as a dental procedure used to facilitate placement of a restoration on a tooth with little or no tooth structure exposed to the oral cavity. Radiographic evidence of fracture or decay that extends below or near the alveolar crest is the usual clinical indication for necessity of the procedure. Aetna considers clinical crown lengthening in conjunction with osseous surgery for periodontal disease inclusive to the osseous surgery.
Clinical crown lengthening is a periodontal procedure in which gingival and osseous tissue is removed in order to expose more clinical tooth structure to the oral cavity. Crown lengthening requires reflection of a flap and osseous recontouring. It is performed in a healthy periodontal environment, as opposed to osseous surgery, which is performed in the presence of periodontal disease. If there are adjacent teeth, the flap design may involve a larger surgical area.
There is limited documentation/information that this procedure can be accomplished with a laser.
In the absence of periodontal disease, a clinical crown lengthening procedure performed on one tooth requires extension of the osseous recontouring to partially include teeth that may be present (contiguous) on either side.
D4249 -- Clinical crown lengthening -- hard tissue
Original policy: September 13, 2004
Updated: September 5, 2007; December 29, 2008; December 21, 2009; February 28, 2011; April 9, 2012; April 30, 2013; March 13, 2014; March 17, 2015
The above policy is based on the following references:
1American Dental Association. Current Dental Terminology, CDT 2014: 33.*
2American Academy of Periodontology. Oral reconstructive and corrective considerations in periodontal therapy. J Periodontol 2005;76:1588-1600. Available at: http://www.joponline.org/doi/pdf/10.1902/jop.2005.76.9.1588. Accessed March 17, 2015.
3American Academy of Periodontology. Parameter on mucogingival conditions. J Periodontol 2000;71:861-862. Available at:
http://www.joponline.org/doi/pdf/10.1902/jop.2000.71.5-S.861. Accessed March 17, 2015.
*Copyright 2014 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.