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Subject: Caries Detection Techniques
Date: May 3, 2023
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.
We consider the use of lasers and other adjunctive caries detection techniques or tools to be part of an oral evaluation or primary service. The use of these tools and/or techniques is not essential to determine or confirm the presence of occlusal, buccal or lingual caries, and can provide false positive results. We consider radiographic interpretation and clinical examination the gold standard for determining the presence of carious lesions.
Caries detection technology may be marketed as qualitative light-induced fluorescence (QLF), fiber-optic transillumination (FOTI), infrared laser fluorescence (ILF) and digital imaging fiber-optic transillumination (DIFOTI).
D0120 — Periodic oral evaluation - established patient
D0140 — Limited oral evaluation - problem focused
D0145 — Oral evaluation for a patient under three years of age and counseling with primary caregiver
D0150 — Comprehensive oral evaluation - new or established patient
D0160 — Detailed and extensive oral evaluation - problem focused, by report
D0425 — Caries susceptibility tests
D0600 — Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin, and cementum
Original: November 22, 2005
Updated: November 28, 2007; February 24, 2009; May 21, 2012; August 12, 2013; June 9, 2014; August 25, 2015; August 22, 2016; November 13, 2017; February 19, 2020; April 5, 2021; May 4, 2022; May 3, 2023
Revised: November 20, 2006; March 29, 2010; March 14, 2011
The above policy is based on the following references:
American Dental Association. CDT 2023 Dental Procedure Codes.
Berg JH. New technologies in pediatric dentistry: dental caries detection and caries management by risk assessment. Contemporary Esthetics. August 2005; Vol. 9 (8): 58.
Bader JD, Shugars DA. A systematic review of the performance of a laser fluorescence device for detecting caries. J Am Dent Assoc 2004 Oct; 135(10):1413-1426.
Barberia E, Maroto M, Arenas M, Cardoso Silva C. A clinical study of caries diagnosis with a laser fluorescence system. J Am Dent Assoc 2008; 139 (5), 572-579.
Copyright 2023 American Dental Association. All rights reserved.
Property of Aetna. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This 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 advice and treatment of members. This Clinical Policy Bulletin may be updated and, therefore, is subject to change.
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Health benefits and health insurance plans contain exclusions and limitations.