Space maintenance in primary dentition (033)

Number: 033
Update

Subject: Space maintenance in primary dentition

Reviewed: August 1, 2024

Important note

This Clinical Policy Bulletin determines whether certain services or supplies are medically necessary, experimental, 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 the 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 an opinion by Aetna 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 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.

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Policy

Space maintenance may be appropriate when one or more of the following conditions are present:
 

• A loss of one or more primary teeth
• Premature loss of primary molars
• Loss in arch perimeter
• A favorable prediction from the space analysis

It is considered esthetic or cosmetic with the early loss of a primary incisor or incisors.

Background

The premature loss of primary teeth from caries, trauma, ectopic eruption or other causes may lead to undesirable tooth movements of primary and/or permanent teeth including loss of arch length. Not every tooth that is lost prematurely requires a space maintainer. If one of the four upper front teeth is lost early, the space will be maintained on its own until the permanent tooth comes in.

Early loss of a primary incisor (teeth identified as D,E,F,G in the upper primary arch, and N,O,P,Q in the lower primary arch) usually results from dental caries or trauma. The early loss of a primary incisor results in very little change in the dentition. Premature loss of primary incisors does not require the placement of appliances for space maintenance because no forward movement of the adjacent teeth is expected when the primary canines have already erupted. Space maintenance is not medically necessary, from a functional perspective, it is generally esthetic or cosmetic concerns that warrant the replacement. The placement of either a removable or fixed partial denture (sometimes referred to as a “kiddie partial”) would be considered esthetic or cosmetic in nature when one or more primary anterior teeth are lost prematurely.

A premature loss of mandibular primary canines is usually a result of large permanent incisor and/or an ectopic eruption. A lateral shift of the incisor teeth can accompany the loss of the primary canine (or canines) and may result in a midline discrepancy. A fixed lingual holding arch may be used to maintain arch integrity and prevent lingual tipping of the mandibular incisors.

An early loss of primary first molars may cause distal drifting of the primary canine if the loss occurs during the active eruption of the permanent lateral incisors. An early loss of the primary second molars may be of concern as the primary second molar helps to guide the eruption of the permanent first molars, especially in the maxillary arch. Various space maintenance techniques may be appropriate for the treatment of the early loss of the primary first and/or primary second molars. Treatment modalities may include, but are not limited to fixed appliances (for example, band and loop, crown and loop, passive lingual arch, distal shoe, Nance appliance, transpalatal arch) or removable appliances (for example, partial denture, Hawley appliance).

Codes

D1510 – Space maintainer - Fixed - Unilateral - per quadrant

D1516 – Space Maintainer Fixed Bilateral Maxillary

D1517 – Space Maintainer Fixed Bilateral Mandibular

D1520 – Space maintainer - Removable - Unilateral - per quadrant

D1526 – Space Maintainer Removable Bilateral, Maxillary

D1527 – Space Maintainer Removable Bilateral Mandibular

D1551 – Re-cement or re-bond bilateral space maintainer – Maxillary

D1552 – Re-cement or re-bond bilateral space maintainer – Mandibular

D1553 – Re-cement or re-bond unilateral space maintainer – per quadrant

D1556 – Removal of fixed unilateral space maintainer – per quadrant

D1557 – Removal of fixed bilateral space maintainer – Maxillary

D1558 – Removal of fixed bilateral space maintainer - Mandibular

D1575 – Distal show space maintainer – fixed - unilateral - per quadrant

Revision dates

Original: November 22, 2005
Updated: November 28, 2007; March 29, 2010; March 14, 2011; July 12, 2012; August 12, 2013; June 9, 2014; June 22, 2015; February 17, 2016; March 2017; April 26, 2018; April 29, 2019; May 13, 2020; October 28, 2021; November 21, 2022; August 16, 2023; August 1, 2024
Revised: November 20, 2006; October 13, 2008; February 24, 2009

The above policy is based on the following references:

American Academy of Pediatric Dentistry. Management of the developing dentition and occlusion in pediatric dentistry. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy  of  Pediatric  Dentistry;  2023:466-83.

Jalan P, Ghosh A, Zahir S, Kundu GK. Esthetic rehabilitation for premature loss of primary anterior teeth. SRM J Res Dent Sci 2019;10:170-2

American Dental Association. CDT 2024 Dental Procedure Codes.

Copyright 2024 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.