Number: 032
(Updated)

Subject: Preventive Resin Restorations

Reviewed: April 26, 2018

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 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.

Policy

We consider the placement of a preventive resin restoration (PRR) to be a treatment for caries found in the pits and fissures in a patient documented to be at moderate-to-high risk of caries. Aetna’s policy is that if decay is present on posterior permanent teeth and it extends into the dentin, the restoration is considered a posterior composite. If the decay (active cavitated lesion) does not extend into the dentin, it is considered a preventive resin restoration. The PRR procedure includes placement of a sealant in any radiating non-carious fissures or pits.

Background

The preventive resin restoration (a combination of composites and/or sealants) is a treatment for caries found in the pits and fissures of posterior permanent teeth in a documented moderate to high caries risk patient when the carious lesion is isolated to the enamel. A patient's caries risk assessment may be evaluated and documented by a variety of methods. 

The use of preventive resin restorations is generally governed by the desire to treat small lesions conservatively, and they are usually placed in the nonstress-bearing regions of the dentition.¹

Codes²

D1352 -- Preventive resin restoration in a moderate to high caries risk patient - permanent tooth

Revision Dates

Original: December 29, 2008

Updated: December 21, 2009; August 8, 2011; September 10, 2012; January 13, 2014; January 26, 2015; February 17, 2016; March 15, 2017; April 26, 2018
Revised: August 23, 2010

The above policy is based on the following references:

¹Dorothy D. McComb, B.D.S., M.Sc.D., FRCD(C). NIH Consensus Development Conference on Caries. Copyright 2000 Regents of the University of Michigan. 2003.

²American Dental Association. CDT 2017 Dental Procedure Codes.*

³American Academy of Pediatric Dentistry. Guidelines on caries-risk assessment and management for infants, children and adloescents. Council on Clinical Affairs. Accessed April 24, 2018.www.aapd.org/media/policies_guidelines/g_cariesriskassessment.pdf

*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.