CurrentAnthemPolicy 04-205

Osseous Surgery (Periodontal)

Defines clinical criteria and limits for coverage of osseous (periodontal) surgery for natural teeth and dental implants, including required preoperative documentation, timing relative to initial therapy, and frequency/quadrant limits. Includes CDT codes for informational purposes.

Policy Summary

PayerAnthem

PolicyOsseous Surgery (Periodontal)

Policy CodePolicy 04-205

Change TypeClarified

Effective DateJan 1, 2025

Next Review Date

Key ActionProvide current (within 12 months) dated 6-point periodontal charting showing pocket depths >= 5mm; documentation may be requested including stage/grade, % bone loss, furcation involvement, and vertical defect description.

SourceLink

POLICY UPDATE CHANGES

Added lines #10 and #11 clarifying requirement for periodontal diagnosis including staging and grading and eligibility timing.

>=5mmMinimum pocket depth for coverage

2Quadrants allowed per date of service

12 monthsMaximum age of charting/radiographs

4 weeksMinimum interval after initial therapy

This policy defines coverage criteria for osseous (periodontal) surgery on natural teeth and dental implants, including required preoperative documentation, timing after initial (non-surgical) therapy, and frequency/quadrant limits. Procedures are considered when there is documented bone loss (horizontal or vertical) with probing depths >= 5mm and bleeding on probing, and when documentation requirements (current 6‑point periodontal charting and diagnostic radiographs or narrative) are met. Benefits are generally limited to two quadrants per date of service, and usually one osseous surgical procedure per period per tooth or multiple teeth in the same quadrant (contract dependent).

Coverage statistics and timing thresholds

Minimum pocket depth for coverage>=5mm

Quadrants allowed per date of service2 (exceptions case-by-case)

Maximum age of charting/radiographsWithin 12 months

Minimum interval after initial therapyMinimum 4 weeks before surgery

Window for surgery relative to initial therapyEligible when performed within 2 years of initial therapy and evaluation

Medically Necessary / Appropriate Criteria

Osseous surgery procedures are considered appropriate when ALL of the following are met:

ALL of the following

Completion of initial periodontal therapy (e.g. scaling and root planing) allowing a minimum of four weeks prior to any surgical treatment for the tissues to properly heal which allows for proper assessment of the success or failure of non-surgical therapy.minimum 4 weeks
see timing after initial therapy
Post initial periodontal therapy (e.g. scaling and root planing) periodontal charting demonstrating pocket depths greater than or equal to 5mm.>= 5 millimeters
minimum pocket depth for coverage
Current (within 12 months), dated, post initial periodontal therapy (e.g. scaling and root planing) 6-point periodontal charting indicating pocket depth recordings of a minimum of 5mm.within 12 months
charting recency
Current (within 12 months), dated, diagnostic, pretreatment radiographic images demonstrating either horizontal and/or vertical osseous defects.within 12 months
radiograph recency
When radiographs are not demonstrative
- A detailed narrative describing periodontal (stage and grade), percentage of bone loss, measured furcation involvement, and description of the vertical defect may be requested.
  documentation may be requested if radiographs non-demonstrative
Only those teeth with favorable periodontal outcomes will be considered for benefit.
Current American Academy of Periodontology (AAP) and American Dental Association (ADA) guidelines require a periodontal diagnosis including staging and grading.
Osseous surgery is considered eligible for benefits when performed within two years of initial therapy and evaluation.within 2 years
window for surgery relative to initial therapy

OpenPayer

Osseous Surgery (Periodontal)

Coverage Summary

Medically Necessary / Appropriate Criteria