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Subject: Resin Infiltration of Incipient Smooth Surface Lesions
Reviewed: November 21, 2022
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 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.
The restoration of a smooth-surface on which decay is present and extends into the dentin is considered a one-surface resin-based composite. Restoration of an incipient lesion that does not extend into the dentin may be reported as a resin infiltration of incipient smooth surface lesion. Infiltrating resin restoration is used for strengthening, stabilizing and/or limiting the progression of the lesion.
This technique is used to treat smooth-surface white-spot lesions microinvasively. It is based on penetrating an early enamel caries lesion with low-viscosity light-curing resins called infiltrants. The surface layer is eroded and desiccated, followed by resin infiltrant application. Driven by capillary force, the resin penetrates into the lesion microporosities and is hardened by light curing.
Infiltrated lesions lose their whitish appearance and look similar to sound enamel.
D2990 – Resin infiltration of incipient smooth surface lesions.
Original policy: October 29, 2012
Updated: January 13, 2014; January 26, 2015; February 17, 2016; March 15, 2017; April 26, 2018; April 29, 2019; May 13, 2020; October 28, 2021; November 21, 2022
The above policy is based on the following references:
American Dental Association. CDT 2023 Dental Procedure Codes.
Dorothy 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.
Shivanna, V., Shivakumar B. Novel treatment of white spot lesions: a report of two cases. J Conserv Dent. 2011 Oct-Dec; 14 (4): 423–426. doi: 10.4103/0972-0707.87217.
American Academy of Pediatric Dentistry (PDF). Council on Clinical Affairs. Guidelines on caries-risk assessment and management for infants, children, and adolescents. Clinical Procedure Guidelines. Vol 37.No 6 15.16. Accessed April 24, 2018.
Copyright 2023 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.
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