ARCHIVED

Medical Policy

Policy Num:      13.003.001
Policy Name:    Endodontic Retreatment
Policy ID:          [13.003.001]  [Ar / L / M+ / P+]  [0.00.00]

Last Review:     November 11, 2020
Next Review:     Policy Archived
Issue:                 11:2020

ARCHIVED

Related Policies BCBS: None

Related Policies TSSS: None

Endodontic Retreatment

Summary

    It is remaking of a contaminated endodontic, in a tooth with a previously root canal treatment.

Objective

Endodontic retreatment includes the removal of pins, restorative material, channel sealing material (gutta percha, silver points, etc.), irrigation (hypochlorite, antibiotic, etc.) and all those procedures, techniques and materials necessary to be able to prepare and seal the channel properly to eliminate reinfection and avoid, tooth extraction.

Policy Statements

If it is necessary to make a retreatment before 5 years, a predetermination is required and this must be accompanied by a detailed report of clinical findings and its necessity with pre-operative periapical radiographic image.

Policy Guidelines

1. It will only be recognizing for payment, one endodontic retreatment per tooth, per life.

2. If it is necessary to make a retreatment before 5 years, a predetermination is required and this must be accompanied by a detailed report of clinical findings        and its necessity with pre-operative periapical radiographic image. (For the Endodontists).

3. Any retreatment requires a predetermination, and this must be accompanied by a detailed report of clinical findings and its necessity, with pre-operative              periapical radiographic image. (Generalist dentist)

4. A predetermination for a retreatment will not be approved or the service recognized for payment, when the same dentist/office performed the original                  treatment. (Generalist dentist).

5. Endodontic retreatment will not be recognized for payment when it is performed for  preventive purposes in asymptomatic teeth which do not show evident        pathology clinical and radiological.

6. Endodontic retreatment includes the removal of pins, restorative material, channel sealing material (gutta percha, silver points, etc.), irrigation (hypochlorite,        antibiotic, etc.) and all those procedures, techniques and materials necessary to be able to prepare and seal the channel properly.

7. Root canal retreatment will not be recognized for payment in cases of contaminated endodontics, as a consequence of the insured not attending to restore        the tooth appropriately.

8. If in a period of 3 months or less the same participant/office proceeds with the extraction of a tooth that he has retreated with a root canal, the payment of the         extraction will be part of the fee paid by the endodontic retreatment.

Benefit Application

BlueCard/National Account Issues

N/A

Background

Definitions of interest;

Periapical abscess;

Is a buildup of pus at the root of a tooth caused by an infection that has spread from a tooth to the surrounding tissues.

Radicular cyst;

Is a cyst arising from epithelial residues in the periodontal ligament as a consequence of inflammation usually following usually following the death of the dental pulp.

Endodonti retreatment;

Is the elimination of reinfection on a previous tooth with root canal treatment by preparing and sealing the

channel properly.

Regulatory Status

N/A

Rationale

Rational of endodontic retreatment is complete debridement removing infected hard or soft tissue of root canal system and obdurate to preserve the health of the residual pulp tissue.

Population Reference No. 1 

Individual: with Reinfected Root Canal Therapy. Intervention of Interest is: Endodontic Retreatment. Comparators of interest is: Extraction. Relevant outcomes include: Maintain Tooth avoiding extraction, Other expensive treatments, Quality of life.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1.    Participating Odontologist Manual 2019, Endodontics, Rules and Limitations of endodontics retreatment.

2.    Participating Endodontist Manual 2019, Endodontics, Rules and Limitations of endodontics retreatment.

3.    Participating Prosthodontist Manual 2019, Endodontics, Rules and Limitations of endodontics retreatment.

Codes

Appplicable Modifiers

N/A

Policy History