Subject: Bone and Tendon Graft Substitutes and Adjuncts
Reviewed: June 22, 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.
D7921 -- Collection and application of autologous blood concentrate product
1 American Dental Association. Dental Procedure Codes, CDT 2015: 75.
Copyright 2014 American Dental Association. All rights reserved.
Original policy: July 12, 2012
Revised: August 12, 2013; June 10, 2014; June 22, 2015
Effective: September 29, 2015
See Medical Clinical Policy Bulletin 0411 -- Bone and Tendon Graft Substitutes and Adjuncts. Revised June 16, 2015: This CPB has been revised to state that the following are considered experimental and investigational: AlloStem, ChronOS bone graft substitute, INFUSE Bone Graft for cervical fusions, and Arthrex biopaste (BioCartilage) for glenoid osteochondral defects and other indicationThe CPB has been revised to add both medically necessary and experimental/investigational products to the Appendices.
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.