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Resin Infiltration of Incipient Smooth Surface Lesions (038)

Number: 038
Update

Subject: Resin Infiltration of Incipient Smooth Surface Lesions

Reviewed: May 13, 2020

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

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. 

Background

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.

Codes1

D2990 - Resin infiltration of incipient smooth surface lesions.

Revision Dates

Original policy: October 29, 2012
Updated: January 13, 2014; January 26, 2015; February 17, 2016; March 15, 2017; Aprio 26, 2018; April 29, 2019; May 13, 2020
Revised: 

The above policy is based on the following references:

1 American Dental Association. CDT 2020 Dental Procedure Codes.*
2 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. 
3 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.    4American Academy of Pediatric Dentistry. 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. http://www.aapd.org/media/policies_guidelines/g_cariesriskassessment.pdf

*Copyright 2019 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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  • Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.
  • While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. 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. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits 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 or the Federal government.
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