Infiltration of sustained release therapeutic drug policy (047)

Number: 047
Update

Subject: Infiltration of Sustained Release Therapeutic Drug 

Reviewed: May 4, 2022

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.

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Policy

Aetna considers the injection of a sustained release analgesic drug into one or more surgical sites to be appropriate for long-acting post-operative pain management in patients who undergo the extraction of impacted third molars. Coverage may be available for this procedure under either the medical or the dental plan, depending on which plan covers the extraction of impacted third molars.

Background

Opioid abuse has reached epidemic proportions in the United States and often begins with a prescription for a pain medication. Dentists are among the leading prescribers of opioid analgesics, and surgical tooth extraction is one of the most frequently performed dental procedures requiring pain control. Surveys suggest that dental practitioners commonly prescribe opioids following this surgical procedure. For patients aged 10 to 19 years, dentists are the main prescribers of opioids.

In a study of dentist opioid prescribing from 2010-2015, oral and maxillofacial surgery accounted for 59% of all procedures performed during a surgical dental visit at which dentists prescribed opioids, and the highest increase in opioid prescribing was among 11- through 18-year-old patients. Other categories of procedures associated with moderate to severe post-op dental pain accounted for a far less significant portion of visits at which dentists prescribed opioids, at 6% and 4% for endodontics and periodontics, respectively.

Regarding potential opioid abuse, when an opioid prescription is filled after impacted third molar extraction, it has been found to be associated with higher odds of continued opioid use among patients who had little or no previous experience taking opioid analgesics.

Aetna continues to advance initiatives to responsibly minimize the prescribing of opioids.  One such initiative is to offer coverage for the long-lasting, non-opioid alternative, EXPAREL (sustained release bupivacaine liposome injectable suspension) when used by an oral surgeon in conjunction with extraction of impacted third molars. Case reports show that one 10ml vial of Exparel is sufficient to treat all four quadrants or thrid molar sites, and claims will be adjudicated accordingly.  Studies indicate that when used with impacted third molar surgery, EXPAREL delivers postsurgical pain relief for 2-3 days following surgery, when pain typically occurs.

EXPAREL is expected to play a meaningful role in helping achieve Aetna’s goal of reducing unnecessary opioid prescriptions by 50% by 2022. The goal of providing coverage for this medication is that oral surgeons who use this sustained release therapeutic drug will reduce the number of opioid tablets or the number of opioid prescriptions they prescribe for impacted wisdom tooth extractions by 50% or more.

Codes

D7220 – Removal of impacted tooth – soft tissue
D7230 – Removal of impacted tooth – partially bony
D7240 – Removal of impacted tooth – completely bony
D7241 – Removal of impacted tooth – completely bony, with unusual surgical complications
D7251 - Coronectomy intentional partial tooth removal
D9613 - Infiltration of sustained release therapeutic drug – single or multiple sites

Review dates

Original policy: October 1, 2018

Update: April 2, 2020; May 4, 2022

Revised: April 27, 2021

The above policy is based on the following references:

Mutlu I, Abubaker  AO, Laskin  DM.  Narcotic prescribing habits and other methods of pain control by oral and maxillofacial surgeons after impacted third molar removal.  J Oral Maxillofac Surg. 2013;71(9):1500-1503.

Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SRB. Characteristics of Opioid Prescriptions in 2009. JAMA : the journal of the American Medical Association. 2011;305(13):1299-1301. doi:10.1001/jama.2011.401.

Opioid prescribing practices from 2010 through 2015 among dentists in the United States. Gupta, Niodita et al. The Journal of the American Dental Association, Volume 149, Issue 4, 237 - 245.e6

Harbaugh CM, Nalliah RP, Hu HM, Englesbe MJ, Waljee JF, Brummett CM. Persistent Opioid Use After Wisdom Tooth Extraction. JAMA. 2018;320(5):504–506. doi:10.1001/jama.2018.9023

Pacira Pharmaceuticals

American Dental Association. CDT 2022 Dental Procedure Codes

Copyright 2022 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.