Subject: Caries Detection Techniques
Date: August 25, 2015
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 refer to 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.
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
D0150 -- Comprehensive oral evaluation - new or established patient
D0160 -- Detailed and extensive oral evaluation - problem focused, by report
Original: November 22, 2005
Updated: November 28, 2007; February 24, 2009; May 21, 2012; August 12, 2013; June 9, 2014; August 25, 2015
Revised: November 20, 2006; March 29, 2010; March 14, 2011
The above policy is based on the following references:
1American Dental Association. CDT 2015 Dental Procedure Codes: 5-6.*
2Berg JH. New technologies in pediatric dentistry: dental caries detection and caries management by risk assessment. Contemporary Esthetics. August 2005; Vol. 9 (8): 58.
3Bader 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.
4Barberia 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 2014 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.