ModifiedAnthemPolicy 04-901

Periodontal Maintenance

Defines clinical indications and criteria for periodontal maintenance (nonsurgical continuing care following definitive periodontal therapy) including coding guidance. Applies to ongoing maintenance for dentition or implants after therapeutic periodontal treatment.

Policy Summary

PayerAnthem

PolicyPeriodontal Maintenance

Policy CodePolicy 04-901

Change TypeRevised

Effective Date01/01/2026

Next Review Date

Key ActionProvider must document prior definitive periodontal therapy with dates and specific treatments rendered to support periodontal maintenance claims.

SourceLink

POLICY UPDATE CHANGES

Policy status shows Revised with last review date 10/27/2025 and publish date 01/01/2026.

6Key clinical criteria lines

6CDT codes listed

Coverage Summary

Policy 04-901 (Subject: Periodontal Maintenance) is covered with criteria. It defines clinical indications and requirements for nonsurgical continuing care following definitive periodontal therapy, applicable to dentition or implants. Effective date: 01/01/2026; Last review date: 10/27/2025.

policy_number04-901

policy_titlePeriodontal Maintenance

effective_date2026-01-01

last_review2025-10-27

statusMODIFIED

scope_summaryDefines clinical indications and criteria for periodontal maintenance (nonsurgical continuing care following definitive periodontal therapy) including coding guidance. Applies to ongoing maintenance for dentition or implants after therapeutic periodontal treatment.

Medical Necessity / Coverage Criteria

Periodontal maintenance is considered appropriate when ALL of the following are met:

History and continuity: History of periodontal therapy and continuous care not exceeding 12 months
Prior definitive therapy documented: Prior history of definitive periodontal therapy with dates and specific treatment rendered
Post-therapy evaluations integral: Post-initial therapy evaluations and treatment planning recommendations following completion of periodontal maintenance are considered integral components of this procedure
Exclusion: A periodontal maintenance procedure is not appropriate when there is no history of periodontal disease requiring definitive periodontal treatment
Exclusion - must have prior definitive periodontal treatment
Documentation requirement: Current American Academy of Periodontology (AAP) and American Dental Association (ADA) guidelines require a periodontal diagnosis including staging and grading
Documentation requirement

Coding (CDT / Diagnosis)

CDT Codes (informational list)mixed

D4341	Periodontal scaling and root planing- four or more teeth per quadrant
D4342	Periodontal scaling and root planing- one to three teeth per quadrant
D4346	Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation
D4381	Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
D4910	Periodontal maintenance
D4999	Unspecified periodontal procedure, by report

ICD-10-CM DiagnosesICD-10

No codes listed

Provider Actions & Documentation Requirements

Documentation Required

Document prior definitive periodontal therapy

Provider must document prior definitive periodontal therapy with dates and specific treatments rendered to support periodontal maintenance claims.

D4910

Documentation Required

Periodontal diagnosis required

Provider must include a periodontal diagnosis including staging and grading per current AAP and ADA guidelines.

Reference AAP/ADA staging and grading

Billing Rule

Coding informational only

Listed CDT codes are provided for informational purposes and do not guarantee coverage; coverage is determined by member contract at time of service.

D4341
D4342
D4346
D4381
D4910
D4999

Background & Evidence

Periodontal maintenance is nonsurgical continuing care after therapeutic periodontal treatment intended to maintain periodontal health for the life of the dentition or implants. It is a demanding, time-consuming therapeutic procedure involving instrumentation of crown and root structures, removal of etiological factors (plaque, biofilm, adherent calculus, diseased cementum), hand instrumentation, and monitoring of disease indicators such as probing depth changes, bleeding on probing, and bone loss changes.

Evidence and guidance referenced include multiple American Academy of Periodontology position papers and statements and related periodontal literature (examples cited: AAP Parameter on Periodontal Maintenance 2000; AAP position paper on periodontal maintenance 2003; AAP statement on local delivery antimicrobials 2006).

Periodontal maintenance

DefinitionNonsurgical continuing treatment following therapeutic periodontal treatment to minimize recurrence and progression of periodontal disease; therapeutic (not prophylactic) care.

Revision History

2025-10-27revised

Policy status shows Revised with last review date 10/27/2025; history indicates annual reviews, minor editorial refinements, and prior addition of CDT code D4346.

2026-01-01revisedLatest

Publish date 01/01/2026 reflecting the revised Dental Clinical Policy (Guideline #04-901) for Periodontal Maintenance.