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Clinical crown lengthening (004)

Number: 004
(Updated)

 

Subject: Clinical crown lengthening

 

Reviewed: April 8, 2020

 

Important note

 

This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical 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 practicing in relevant clinical areas, and other relevant factors).

 

Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in this Bulletin. The discussion, analysis, conclusions and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna’s opinion and are made without any intent to defame.

 

Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.

 

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.

 

The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (for example, will be paid for by Aetna) for a particular member. The member's benefit 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, the Federal government or CMS for Medicare and Medicaid members.

 

Visit the CMS coverage database

 

Policy

 

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.

 

Background

 

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 removal of bone to alter the crown-to-root ratio. A healing period is required before establishment of crown margins and taking the final impression. Crown lengthening is performed in a healthy periodontal environment, as opposed to osseous surgery, which is performed when periodontal disease is present. 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.

 

If there is no 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.

 

Codes1

 

D4249 -- Clinical crown lengthening -- hard tissue

 

Revision dates

 

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; April 28, 2016; April 27, 2017; April 26, 2018; April 29, 2019; April 8, 2020

 

Revised: December 5, 2005

 

The above policy is based on the following references:

 

1American Dental Association. CDT 2020 Dental Procedure Codes.* 

2American Academy of Periodontology. Oral reconstructive and corrective considerations in periodontal therapy (PDF). J Periodontol2005;76:1588-1600. doi/pdf/10.1902/jop.2005.76.9.1588.  Accessed March 17, 2015.

3American Academy of Periodontology. Parameter on mucogingival conditions (PDF). J Periodontol2000;71:861-862. doi/pdf/10.1902/jop.2000.71.5-S.861. Accessed March 17, 2015.

 

*Copyright 2019 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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