Osseous Surgery (012)

Number: 012
(Updated)

Subject: Osseous Surgery

Date: January 13, 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 surgery procedures under either medical or dental plans.

Background

Periodontal disease is a disease process that negatively affects the alveolar bone that supports the teeth. It is associated with increased clinical probing depths and demonstrated radiographic evidence of horizontal and/or vertical osseous defects.

To prevent progression of the disease, treatment is directed toward

• Improving home care
• Reducing plaque/biofilm
• Treating of local factors such as defective restorations
• Reviewing systemic health, including consultation with medical providers to modify medications and /or dental treatment as necessary
• Removing associated calculus buildup (scaling and root planing to remove plaque and calculus from periodontal pockets and to smooth the tooth root to remove bacterial toxins)

When scaling and root planing of the teeth cannot halt progression of the disease it is necessary to address these defects surgically. This is defined as osseous surgery.

Osseous surgery is a minor dentoalveolar surgical procedure that may be necessary for isolated defects of supporting bone or for more generalized regions that involve an entire quadrant. A quadrant is defined as one of the four equal sections into which the dental arches can be divided. It begins at the midline of the arch and extends distally to the last tooth.¹

The surgical procedure requires development of a full mucoperiosteal flap reflection of the gingiva (gums), underlying connective tissue and periosteum for access to the osseous defects and root surfaces of teeth. The procedure modifies the bony support of the teeth by reshaping the alveolar process to achieve a more physiologic form. This may include the removal of minor amounts of affected, supporting bone and/or nonsupporting bone.

Osseous surgery is one of the most common periodontal procedures performed for surgical correction of osseous defects. In addition, if bone defects are severe enough, a bone graft and membrane may be necessary.

The necessity of the surgical procedure/s will be determined by a detailed clinical examination, dental history review, medical history review, oral hygiene review, necessary diagnostic tests, consultations with other health care professionals, and diagnostic procedures such as radiographs and periodontal charting.

Refer to CPB #13 -- Bone Replacement Grafts.

Codes^2,3

D4260 -- Osseous surgery (including flap entry and closure) -- four or more contiguous teeth or tooth bounded spaces per quadrant
D4261 -- Osseous surgery (including flap entry and closure) -- one to three contiguous teeth or tooth bounded spaces per quadrant

Revision Dates

Original: November 22, 2005
Updated: November 28, 2007; December 29, 2008; December 21, 2009; February 28, 2011; December 4, 2012; January 13, 2014
Revised: November 20, 2006

The above policy is based on the following references:

1 American Dental Association. Current dental terminology, CDT 2011-2012; 231.*

2 American Dental Association. Current dental terminology, CDT 2011-2012; 27.*

3 American Dental Association. CDT 2013: Dental Procedure Codes: 31.**

4 American Academy of Periodontology. Parameter on chronic periodontitis with slight to moderate loss of periodontal support. J Periodontal. 2000; 71:853-855.

5 American Academy of Periodontology. Parameter on chronic periodontitis with advanced loss of periodontal support. J Periodontal. 2000; 71:856-858.

6 American Academy of Periodontology. Parameter on comprehensive periodontal examination. J Periodontal. 2000; 71:847-848.

*Copyright 2010 American Dental Association. All rights reserved.

**Copyright 2012 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.