CurrentAnthemPolicy 04-301

Scaling and Root Planing

Defines clinical and documentation criteria for review of periodontal scaling and root planing (D4341, D4342) as a nonsurgical therapeutic procedure for treatment of periodontal disease; includes required diagnostic documentation and adjunctive criteria for payment determination. Clarifies that inclusion of codes is informational and coverage depends on member contract.

Policy Summary

PayerAnthem

PolicyScaling and Root Planing

Policy CodePolicy 04-301

Change TypeRevised (annual review)

Effective DateJan 1, 2021

Next Review Date

Key ActionSubmit full mouth radiographs and 6‑point periodontal pocket depth charting labeled and dated within 12 months, and document ≥4 mm pocket depths with bleeding and radiographic bone loss (>1.5 mm apical to CEJ) to support payment.

SourceLink

POLICY UPDATE CHANGES

Policy status marked Revised with revision history entries including annual reviews and wording/criteria updates through 12/04/2020.

2Primary CDT codes listed

>=4 mmPocket depth threshold

12 monthsRequired documentation recency

Coverage Summary

Scaling and root planing (CDT codes D4341, D4342) is a nonsurgical periodontal procedure used to treat periodontal disease by removing plaque, calculus, and diseased cementum and dentin. Coverage determination is dependent on clinical documentation and the member's contract (contractual benefits and plan rules apply). Refer to policy number 04-301; policy publish date is 01/01/2021 with last review on 12/04/2020.

Medically Necessary / Coverage Criteria

Medically Necessary / Coverage Criteria for Scaling and Root Planing

Covered when ALL of the following are met:

ALL of the following

Procedure is periodontal scaling and root planing — a non-surgical therapeutic procedure to treat periodontal disease involving removal of cementum and dentin permeated by calculus, toxins, and microorganisms.
ALL of the following
- Full mouth radiographic images and/or a panoramic radiographic image including bitewings; labeled and dated within 12 months of submitted procedurewithin 12 months
- Periodontal charting: 6-point periodontal pocket depth charting as described by ADA and AAP; labeled and dated within 12 months of submitted procedurewithin 12 months
ALL of the following
- At least ONE of
  - Migration of the epithelial attachment has caused formation of periodontal pockets of at least 4 mm>= 4 mm
  - Clinically evident inflammation and/or bleeding on probing
- ALL of the following
  - Demonstrable radiographic evidence of bone loss (vertical or horizontal) of the alveolar crest; bone loss considered as bone level > 1.5 mm apical to the CEJ> 1.5 mm apical to the CEJ
  - Teeth to be treated must demonstrate at least 4-millimeter pocket depths and bleeding on probing
ALL of the following
- Performed utilizing hand instrumentation and/or ultrasonic scalers
- Performed utilizing local anesthesia by intramucosal injection (topical or subgingival anesthetics do not qualify as local anesthesia for these procedures)
ALL of the following
- For a partial quadrant: at least 1 tooth in the quadrant has a pocket depth of 4 mm or more>= 1 tooth with >=4 mm
- For a full quadrant: at least 4 teeth in the quadrant have pocket depths of 4 mm or more>= 4 teeth with >=4 mm
- Additional documentation may be requested when more than two quadrants are performed in one appointment
ALL of the following
- Chronic periodontitis
- Localized and generalized aggressive periodontitis
- Localized and generalized periodontitis as a manifestation of systemic disease
- Necrotizing periodontal diseases
ALL of the following
- Gingival diseases, plaque-induced or non-plaque induced, would not qualify for payment
ALL of the following
- Scaling and debridement of implants is considered inclusive with D4341 and D4342
- Post-initial therapy evaluations and treatment planning recommendations following completion of scaling and root planing are integral components of the procedure

Provider Documentation & Submission Requirements

Documentation Required

Provide radiographs and periodontal charting

Submit full‑mouth radiographs or a panoramic image with bitewings plus a 6‑point periodontal pocket depth charting; all images/charting must be labeled and dated within 12 months of the procedure to support review and payment for scaling and root planing.

Affected codes: D4341, D4342
Requirement: Images and periodontal charting labeled and dated within 12 months

Documentation Required

Document pocket depths and bleeding

Document clinical periodontal findings including pocket depths of at least 4 mm with bleeding on probing and demonstrable radiographic bone loss (bone level > 1.5 mm apical to the CEJ) to support payment.

Affected codes: D4341, D4342
Thresholds: pocket depths >= 4 mm; radiographic bone loss > 1.5 mm apical to CEJ; evidence of bleeding on probing

Documentation Required

Document anesthesia and instrumentation

Document that the procedure was performed using intramucosal local anesthesia (topical or subgingival anesthetics alone do not qualify) and record the instrumentation method used (hand and/or ultrasonic scalers).

Affected codes: D4341, D4342
Note: Topical or subgingival anesthetics alone are insufficient; intramucosal injection required
Document instrumentation: hand and/or ultrasonic

Documentation Required

Additional documentation for multi-quadrant procedures

Be prepared to supply additional clinical and/or administrative documentation when more than two quadrants of scaling and root planing are performed in a single appointment.

Affected codes: D4341, D4342
Additional documentation may be requested for >2 quadrants treated in one visit

Background, Evidence & Definitions

Scaling and root planing is a technique-sensitive therapeutic procedure performed to remove plaque, biofilm, adherent calculus deposits, and diseased cementum/root structure using hand instrumentation and/or ultrasonic scalers, typically under local anesthesia (intramucosal injection). It is commonly performed with local anesthetic and hand or ultrasonic instruments; because it is technique-sensitive and time-consuming, appropriate clinical documentation (diagnostic radiographs, 6-point periodontal charting, pocket depths, bleeding on probing, and radiographic bone loss) is required and payment is subject to the member's contract.

Source	Reference
Systematic review citation	Smiley CJ et al., J Am Dent Assoc. 2015;146(7):508-524
Guideline source	American Academy of Periodontology Parameter on chronic periodontitis

Term	Definition
Bone loss	Bone level greater than 1.5 mm apical to the cementoenamel junction (CEJ)
Full quadrant	At least 4 teeth in the quadrant have pocket depths of 4 mm or more
Partial quadrant	At least 1 tooth in the quadrant has a pocket depth of 4 mm or more

Revision History

2019-03-04revision

Revision entry in history (3-4-19) documenting earlier external-facing policy revision.

2019-04-22revision

Revision entry in history (4/22/19) noting criteria numbering changes.

2019-07-23revision

Revision entry in history (7/23/19) capturing verbiage updates.

2020-05-20revision

Revision entry in history (5/20/2020) listed as Annual revision.

2020-12-04reviewLatest

Annual review recorded (12/04/2020); policy status marked Revised with revision history entries through this date.

2021-01-01publish

Clinical Dental Policy publish date 01/01/2021.

Policy Summary

PayerAnthem

PolicyScaling and Root Planing

Policy CodePolicy 04-301

Change TypeRevised (annual review)

Effective DateJan 1, 2021

Next Review Date

SourceLink

On This Page

D1110	Prophylaxis adult
D1120	Prophylaxis child
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 exam

OpenPayer

Scaling and Root Planing

Coverage Summary

Medically Necessary / Coverage Criteria

Provider Documentation & Submission Requirements

Coding

Background, Evidence & Definitions

Key Thresholds & Clinical Requirements

Revision History