Number: 048
New

Subject: Dental Radiographic Examinations 

Reviewed: September 23, 2019

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 CMS's Coverage Database  

Policy

Necessity and appropriateness of dental radiographic images will be determined through review of submitted services and their alignment with the guidelines outlined in the American Dental Association/Food & Drug Administration report, “Dental Radiographic Examinations: Recommendations for Patient Selection and Limiting Radiation Exposure.” The need for radiographic images will be assessed by weighing the potential diagnostic yield against the risk of radiation exposure.

Background

Radiographs can help the dental practitioner evaluate and definitively diagnose many oral diseases and conditions. However, the dentist must weigh the benefits of taking dental radiographs against the risk of exposing a patient to x-rays, the effects of which accumulate from multiple sources over time.

Dentists should only order radiographs when they expect that the additional diagnostic information will affect patient care. This approach will optimize patient care, minimize radiation exposure and responsibly allocate health care resources.

Radiographic screening for the purpose of detecting disease before clinical examination should not be performed. A thorough clinical evaluation, consideration of the patient history, review of any prior radiographs, caries and/or periodontal risk assessment and consideration of both the dental and the general health needs of the patient should precede radiographic imaging.  Furthermore, radiographic images should not be taken at regular intervals (for example, every recall appointment) without a diagnostic rationale based on the aforementioned assessment.

Once a decision to obtain radiographs is made, it is the dentist's responsibility to follow the ALARA Principle (As Low as Reasonably Achievable) to minimize the patient's exposure to radiation. Examples of good radiologic practice include:

• proper film exposure and processing techniques
• use of protective aprons and thyroid collars, when appropriate
• limiting the number of images obtained to the minimum necessary to obtain essential diagnostic information 

In dental plans that cover dental radiographic images, the available benefit may be limited as to the number and/or frequency of images, in keeping with ADA/FDA guidelines. Accordingly, the benefit for other intraoral or extraoral dental images may be limited as well. 

Codes⁶

D0210 – Intraoral - complete series of radiographic images
D0220 – Intraoral - periapical first radiographic image
D0230 – Intraoral - periapical each additional radiographic image
D0240 – Intraoral - occlusal radiographic image
D0250 - Extra-oral – 2D projection 
D0251 - Extra-oral posterior dental radiographic image
D0270 - Bitewing - single radiographic image
D0272 - Bitewings - two radiographic images
D0273 - Bitewings - three radiographic images
D0274 - Bitewings - four radiographic images
D0277 - Vertical bitewings - 7 to 8 radiographic images
D0310 - Sialography
D0320 - Temporomandibular joint arthrogram, including injection
D0321 - Other temporomandibular joint radiographic images, by report
D0322 - Tomographic survey
D0330 - Panoramic radiographic image
D0340 - 2D cephalometric radiographic image – acquisition, measurement and analysis
D0350 - 2D oral/facial photographic image obtained intra-orally or extra-orally
D0351 - 3D photographic image
D0364 - Cone beam CT capture and interpretation with limited field of view – less than one whole jaw
D0365 - Cone beam CT capture and interpretation with field of view of one full dental arch – mandible
D0366 - Cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium
D0367 - Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium
D0368 - Cone beam CT capture and interpretation for TMJ series including two or more exposures
D0369 - Maxillofacial MRI capture and interpretation
D0370 - Maxillofacial ultrasound capture and interpretation
D0371 - Sialoendoscopy capture and interpretation
D0380 - Cone beam CT image capture with limited field of view – less than one whole jaw
D0381 - Cone beam CT image capture with field of view of one full dental arch – mandible
D0382 - Cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium
D0383 - Cone beam CT image capture with field of view of both jaws; with or without cranium
D0384 - Cone beam CT image capture for TMJ series including two or more exposures  

Review dates

Original policy: September 23, 2019

The above policy is based on the following references:

¹American Dental Association. CDT 2019 Dental Procedure Codes.*

²The Selection of Patients for Dental Radiographic Examinations https://www.fda.gov/radiation-emitting-products/medical-x-ray-imaging/selection-patients-dental-radiographic-examinations

*Copyright 2018 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.