Number: 037
(Revised)

Subject: Bone and Tendon Graft Substitutes and Adjuncts

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. 

Visit the CMS's Coverage Database

See Medical Clinical Policy Bulletin 0411

CDT Codes¹

D7921 -- Collection and application of autologous blood concentrate product

Reference

¹ American Dental Association. CDT 2017 Dental Procedure Codes:.

Copyright 2016 American Dental Association. All rights reserved.

Revision dates

Original policy: July 12, 2012
Updated:
Revised: August 12, 2013; June 10, 2014; June 22, 2015; June 28, 2016; June 26, 2017

Effective: September 29, 2015

See Medical Clinical Policy Bulletin 0411 -- Bone and Tendon Graft Substitutes and Adjuncts. March 29, 2017: This CPB is revised to state that the INFUSE Bone Graft is considered medically necessary for lumbar spinal fusion procedures in skeletally mature persons who meet the following criteria: 1) INFUSE Bone Graft is to be used with a cage; 2) INFUSE Bone Graft and device is to be implanted via an anterior approach; 3) the member meets medical necessity criteria for lumbar spinal fusion; and 4) the use of autograft is unfeasible.

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.