Number: 031
(Update)

Subject: Odontogenic Cysts

Reviewed: June 26, 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

We consider the removal of odontogenic cysts medically necessary when a differential diagnosis has accurately identified the presence of a lesion. Odontogenic cyst enucleation is considered by Aetna to be a distinct procedure when performed independently of other related surgical procedures. When performed concomitantly and in the same location as surgical tooth extraction, removal of an impacted tooth or an apicoectomy, we consider the removal of the cyst to be part of the related surgical procedure and a separate benefit would not be available for the cyst removal. However, when the expansion of the cyst is evident outside of the confines of the tooth or tooth socket area, the removal of the cyst may be considered as a separate procedure.

Nonodontogenic cysts, odontogenic tumors and other related tumors of the jaw are not addressed by this policy.

Background

All true odontogenic cysts are characterized by an epithelial lining. These cysts grow by expansion, and in doing so are identified radiographically by their characteristic radiolucency. They are believed to arise from the proliferation of normally quiescent epithelial cells in the jaw (that is, gingival rests of Serres, rests of Malassez). Cysts can be divided into inflammatory and developmental categories.

Inflammatory cysts

Radicular (periapical) cyst - This is the most common odontogenic cyst (65% of all odontogenic cysts) and is thought to arise from the epithelial cell rests of Malassez in response to inflammation. Radiographic findings could be indicative of a nonvital tooth that has a small well-defined periapical radiolucency at its apex. Large cysts may involve a complete quadrant with some of the teeth occasionally mobile and some of the pulps nonvital. Root resorption may be seen. The cyst is painless when sterile and painful when infected. Treatment is extraction of the affected tooth and its periapical soft tissue or root canal (and potential periradicular surgery) if the tooth can be preserved.

Paradental cyst - An inflammatory cyst forming most often along the distal or buccal root surface of partially impacted mandibular third molars, this cyst is thought to be the result of inflammation of the gingiva overlying a partly erupted third molar. Radiographically, it presents as a radiolucency in the apical portion of the root and represents from 0.5% to 4% of all odontogenic cysts. Treatment is by enucleation.

Developmental cysts

Dentigerous (follicular) cyst - This is the most common developmental cyst (24% of all developmental cysts) and is thought to originate through the accumulation of fluid between reduced enamel epithelium and a completed tooth crown. It is usually found in conjunction with the mandibular third molars, maxillary canines and maxillary third molars. These cysts are most prevalent in the second to fourth decades. Radiographically, a unilocular radiolucency with well-defined sclerotic margins encircling the crown of an unerupted tooth is seen. The treatment for this type of cyst is enucleation. If the cyst is large, the treatment may be decompression, followed by enucleation.

Lateral periodontal cyst - This cyst may arise from epithelial rests in the periodontal ligament, or may represent a primordial cyst originating from a supernumerary tooth bud. It is most frequently encountered in the mandibular premolar region in adult men over 40 years. On a radiographic image, this cyst is an interradicular radiolucency with well-defined or corticated margins. The adjacent teeth are vital and usually show some degree of root divergence. The treatment is surgical enucleation or curettage with preservation of adjoining teeth.

Odontogenic keratocyst (OKC) - This is a specific and microscopically distinct form of odontogenic cyst that may assume the character of any of the odontogenic cysts. OKC comprises approximately 11% of all cysts of the jaws and are most often seen in the mandibular ramus and angle. It may be associated with the crown of a tooth appearing as a dentigerous cyst or may represent a keratinizing variant of the lateral periodontal cyst. Radiographically, it can mimic any of the jaw cysts and may appear as a well-marginated inter-radicular radiolucency, a pericoronal radiolucency or a multilocular radiolucency. Small OKCs may be treated with simple enucleation if the entire cyst lining can be removed. Association with an impacted tooth requires removal of the tooth and enucleation of the cyst. 

Codes³

D7450 -- Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm
D7451 -- Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm

Revision dates

Original policy: March 12, 2007
Updated: March 29, 2010; March 14, 2011; May 21, 2012; August 12, 2013; June 9, 2014; June 22, 2015; June 28, 2016; June 26, 2017
Revised: April 29, 2008; March 30, 2009

The above policy is based on the following references:

¹Cysts and Cystic Lesions of the Mandible: Clinical and Radiologic-Histopathologic Review : Robert J. Scholl, MD; Helen M. Kellett, MD; David P. Neumann, MD and Alan G. Lurie, DDS, PhD. From the Department of Diagnostic Imaging and Therapeutics, School of Medicine (R.J.S., H.M.K., D.P.N.) and the Department of Oral Diagnosis, Division of Oral and Maxillofacial Radiology, School of Dental Medicine (A.G.L.), University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030. Presented as a scientific exhibit at the 1997 RSNA scientific assembly. Received April 13, 1998; revision requested May 22; final revision received February 17, 1999; accepted February 17.

²Odontogenic Cysts and Tumors, Grand Rounds Presentation, UTMB, Dept. of Otolaryngology: Michael Underbrink, MD, MBA, Anna Pou, MD, Francis B. Quinn, Jr., MD and Matthew W. Ryan, MD. February 13, 2002

³American Dental Association. CDT 2017 Dental Procedure Codes:.*

*Copyright 2016 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.