Number: 010
(Update)

Subject: Alveoloplasty -- surgical preparation of ridge 

Date: September 9, 2017

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. 

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Policy

Aetna considers this surgical procedure to be dental-in-nature (DIN) oral surgery. Coverage may be available for DIN oral surgical procedures under either medical or dental plans.

Background

Alveoloplasty, in conjunction with extractions, is a surgical procedure that recontours the alveolar bone and is usually performed to prepare the alveolar ridge for a dental prosthesis or other treatments such as radiation therapy and transplant surgery. This procedure may require the elevation of a mucoperiosteal flap to allow access to the alveolar cortical bone of the maxilla (upper jaw) or mandible (lower jaw). Protuberant or excessive cortical bone not removed during the extraction procedure would be removed during an alveoloplasty procedure with additional surgical instrumentation. This procedure is usually reported separately from the removal of teeth within the same quadrant on the same date of service.

Alveoloplasty, not in conjunction with extraction of teeth, is defined as the removal of bone within a quadrant and is usually performed to accommodate the placement of a dental prosthesis or other treatments such as radiation therapy and transplant surgery. This procedure is the same procedure as that noted above, except that there is no report of tooth removal on the same date of service. The surgical procedure involves mucoperiosteal flap elevation and removal of protuberant bone that has been determined to have an adverse effect on stability and comfort for a future dental prosthesis.

A quadrant, as defined in CDT 2011-2012, is one of the four equal sections into which the dental arches can be divided. A quadrant begins at the midline of each arch and extends distally to the last tooth. ¹ Each quadrant includes up to eight teeth or tooth spaces.

Codes

CDT ²:
D7310 -- Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
D7311 -- Alveoloplasty in conjunction with extractions, one to three teeth or tooth spaces per quadrant
D7320 -- Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant
D7321 -- Alveoloplasty not in conjunction with extractions, one to three teeth or tooth spaces per quadrant

CPT ³:
41874 -- Alveoloplasty, each quadrant

Revision dates

Original policy: November 22, 2005
Updated: November 28, 2007; December 29, 2008; December 21, 2009; February 28, 2011; April 9, 2012; April 30, 2013; April 17, 2014; April 20, 2015; May 23, 2016; September 5, 2017
Revised:

The above policy is based on the following references:

¹American Dental Association. CDT 2017 Dental Procedure Codes.*

²American Medical Association. Current procedural terminology, CPT-2011: 153.**

³Kruger, Gustav O. Complicated Exodontics, Chapter 5, Preprosthetic Surgery. Chapter 8, Textbook of Oral Surgery. St. Louis: C V Mosby Company; 2002: 71-76: 111-119.

⁴Archer, W. Harry. Oral Surgery for Dental Prostheses, Chapter 3, Oral and Maxillofacial Surgery. Carlsbad: W.B. Saunders; 1975:179-182.

*Copyright 2016 American Dental Association. All rights reserved.
**Copyright 2010 American Medical 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.