Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.
Blue Cross and Blue Shield of Montana (BCBSMT) considers d
- Ultrasonograph scans and interpretation (e.g., Cavitat™); OR
- Surgery, including but not limited to
- Debridement, or
- Scraping, or
- Curettage, or
- Any other method of removal of “cavitations”; OR
- Bone graft replacement; OR
- Any other therapy, including but not limited to
- Rinsing “cavitations” with saline and/or colloidal silver; or
- Administration of chelation therapy and intravenous vitamin C.
The clinical significance of NICO has not been established; many etiologies for NICO have been suggested, but none have been substantiated through research and scientific evidence. In addition, there is no agreement within the dental community on the clinical significance of these cavitations, and there are no clear diagnostic or treatment criteria that are widely accepted and integrated into clinical practice.
A MedLine search on the terms NICO, cavitational, and osteonecrosis located eight articles, six of which were authored or co-authored by one particular dentist who is a proponent of NICO; none of the articles report randomized, controlled studies on the diagnosis and/or treatment of NICO. The biopsies that have reportedly confirmed a diagnosis of NICO are performed on tissue that has been tested after-the-fact following invasive surgery. Further, the available literature suggests that only one specific pathologist has confirmed the NICO diagnosis on biopsy. In addition, an FDA 510K approval of the CAVITAT™ only addresses the safety and not the effectiveness of the device. In the 510K approval the FDA states, “The clinical significance and correlation of the CAVITAT™ (Ultrasonograph) images, including column height and color grading, has not been established for specific osseous pathology, or normal bone. Positive images represent alveolar regions that attenuate ultrasound signals.”
The diagnosis and treatment of NICO is not supported by a coverage position of the Centers for Medicare and Medicaid Services (CMS) or other authoritative guidelines.
An updated MedLine literature review was conducted through May 2008.. Diagnosis and treatment of NICO is not supported by evidence in the peer-reviewed medical literature that demonstrates an improvement in net health outcome and/or permits conclusions on the effect on health outcomes.
Sciubba (2009) reported that neuralgia-inducing cavitational osteonecrosis remains controversial. Changing etiologic concepts have led to confusion as well as the significant departures from the concept first defined by Ratner, which served as the basis for explaining the pain syndrome with features of trigeminal neuralgia. Since the earliest publications on the subject by Bouquot and colleagues there have been many challenges and counterclaims to the concept introduced, with a discussion of these included. Finally, absence of any form of research design and approval by institutional review panels remains a weakness in terms of acceptance of the information provided in the literature said to support the stated etiology of this entity.
The American Association of Endodontists (AAE) published a 2012 Position Statement on NICO lesions (Neuralgia-Inducing Cavitational Osteonecrosis) that states they "cannot condone surgical interventions intended to treat suspected NICO lesions. Even when a NICO lesion is suspected to be associated with an endodontically treated tooth, no surgical procedures should be performed until orofacial pain specialists confirm the diagnosis. It is also recommended that the treatment be performed and followed up by the orofacial pain specialists. In addition, the practice of recommending the extraction of endodontically treated teeth for the prevention of NICO, or any other disease, is unethical and should be reported immediately to the appropriate stated board of dentistry.”
A search of peer reviewed literature through June 2013 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.