Audience
Zip code - drawer
County - drawer

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Policy No:  36L

Originally Created: 01/01/2000

Section: Periodontics

Last Reviewed:  01/01/2019

Last Revised:  01/01/2018

Approved: 01/01/2018

Effective:  01/01/2018

Description

Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report (D4381)

  • Synthetic fibers or other approved delivery devices containing controlled-release chemotherapeutic agent(s) are inserted into a periodontal pocket. Short term use of the timed release therapeutic agent as supplemental or adjunctive therapy provides for reduction of subgingival flora. This procedure does not replace conventional or surgical therapy required for debridement, resective procedures or for regenerative therapy.
  • The use of controlled-release chemotherapeutic agents is an adjunctive procedure for specific sites that are unresponsive to conventional therapy or for cases in which systemic disease or other factors preclude conventional or surgical therapy.

Policy/criteria

Procedure is in accordance with generally accepted standards of dental practice.

Not a covered benefit due to lack of published evidence of long-term clinical efficacy.  Examples of chemotherapeutic agents are:

  • Actisite
  • Arrestin
  • PerioChip

Administrative guidelines

Process to contract benefits.

Codes

CDT - D4000-D4999

Disclaimer

Your use of this Dental Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Dental Policy Disclaimer.