Alveoloplasty - surgical preparation of ridge in preparation for a prosthesis (010)

Number: 010
(Update)

Subject: Alveoloplasty -- surgical preparation of ridge in preparation for a prosthesis

Date: April 17, 2014

Important Note

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:

• Clinical outcome studies in the peer-reviewed published medical and dental 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 and dentists practicing in relevant clinical areas
• Other relevant factors

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.

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
Revised:

The above policy is based on the following references:

1 American Dental Association. Current dental terminology, CDT 2014: 70.*

2 American Medical Association. Current procedural terminology, CPT-2010: 153.**

3 Kruger, 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.

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

*Copyright 2013 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.