CurrentAnthemPolicy 04-301

Dental Clinical Policy

Clinical guideline defining documentation and clinical criteria used by the plan to review medical/dental necessity for scaling and root planing (non-surgical periodontal therapy). It outlines required diagnostic information, clinical thresholds for treatment, qualifying diagnoses, exclusions, and relevant CDT procedure codes for review purposes.

Policy Summary

PayerAnthem

PolicyDental Clinical Policy

Policy CodePolicy 04-301

Change TypeRevised (multiple annual reviews)

Effective DateJan 1, 2022

Next Review Date

Key ActionProviders must submit labeled and dated full mouth radiographs/panoramic with bitewings and 6-point periodontal pocket depth charting dated within 12 months for review of scaling and root planing.

SourceLink

POLICY UPDATE CHANGES

Policy status marked as Revised; revision history includes multiple committee annual reviews and verbiage/criteria updates.

3Primary CDT codes listed

>=4 mmPocket depth threshold

1.5 mmRadiographic bone loss threshold

Coverage Summary

This guideline addresses Scaling and Root Planing, a non-surgical periodontal therapy used to remove plaque, calculus and diseased cementum in patients with periodontal pockets. It is a clinical guideline the plan uses to determine whether services meet generally accepted standards of dental care and contractual coverage requirements, and it specifies required diagnostic documentation, clinical thresholds, qualifying diagnoses, exclusions, and relevant CDT procedure codes for review.

Medical Necessity Criteria

Documentation Requirements (precondition)

Covered when ALL of the following documentation elements are provided for review:

ALL of the following

Full mouth radiographic images and/or a panoramic radiographic image including bitewings radiographs; labeled and dated (within 12 months of submitted procedure)
Periodontal Charting; 6-point periodontal pocket depth charting; labeled and dated (within 12 months of submitted procedure)

Clinical Criteria for Scaling and Root Planing

Coverage/medical necessity requires ALL of the following unless otherwise noted:

ALL of the following

Clinical thresholds: Teeth to be treated must demonstrate at least 4-millimeter pocket depths, bleeding on probing, with demonstrable radiographic evidence of bone loss (vertical or horizontal) of the alveolar crest.>= 4 mm pocket depth; bone loss > 1.5 mm apical to CEJ
Bone loss defined as bone level greater than 1.5 mm apical to the cementoenamel junction (CEJ).
Anesthesia: Administration of local anesthesia by intramucosal injection is required; topical anesthetics or subgingival anesthetic preparations do NOT qualify as local anesthesia.
Quadrant threshold
- Partial quadrant: at least 1 tooth with pocket depth >= 4 mm>= 4 mm
- Full quadrant: at least 4 teeth with pocket depths >= 4 mm>= 4 mm (>=4 teeth)
Qualifying diagnoses
- Chronic periodontitis
- Localized aggressive periodontitis
- Generalized aggressive periodontitis
- Localized periodontitis as a manifestation of systemic disease
- Generalized periodontitis as a manifestation of systemic disease
- Necrotizing periodontal diseases

Administrative / Additional Review Criteria

Additional documentation or constraints that may be required for review:

ALL of the following

Treatment time documentation: Documentation of the duration of treatment times for periodontal scaling and root planing may be required for individual case review, especially when more than two quadrants are treated in one appointment.
Clinical parameters: Other than 4-millimeter pocket depths, parameters for periodontal therapy include clinically evident inflammation and/or bleeding.
Post-therapy evaluations: Post-initial therapy evaluations and treatment planning recommendations following completion of scaling and root planing are considered integral components of this procedure.
More than two quadrants:

Exclusions / Not Covered Conditions

The following conditions do NOT qualify for payment:

ALL of the following

Gingival diseases, plaque induced or non-plaque induced, do not qualify for payment
Implant scaling billing: Scaling and debridement of implants is considered inclusive with D4341 and D4342 (not separately billable)

Denial Risk

Claims may be denied for gingival diseases without periodontitis

Procedures for gingival diseases (plaque induced or non-plaque induced) do not qualify for payment and may be denied if submitted as scaling/root planing without documentation of qualifying periodontitis.

Provider Actions / Documentation Requirements

Documentation Required

Submit diagnostic imaging and periodontal charting

Providers must submit labeled and dated full mouth radiographs and/or a panoramic radiograph including bitewings, and 6‑point periodontal pocket depth charting, all dated within 12 months, for review of scaling and root planing.

radiographs & periodontal charting dated within 12 months

Documentation Required

Document local anesthesia administration

Documentation must show administration of local anesthesia by intramucosal injection. Topical anesthetics or anesthetic preparations placed subgingivally do NOT qualify as local anesthesia for scaling and root planing.

Documentation Required

Provide treatment time documentation when requested

Documentation of the duration of treatment times for periodontal scaling and root planing may be requested for individual case review, particularly when more than two quadrants are treated during a single appointment.

Denial Risk

Claims may be denied for gingival diseases without periodontitis

Gingival diseases alone (plaque induced or non-plaque induced) are excluded from payment and claims may be denied if submitted without documentation of a qualifying periodontitis diagnosis (for example, chronic periodontitis, aggressive forms, periodontitis as manifestation of systemic disease, or necrotizing periodontal diseases).

Background, Evidence & Definitions

Scaling and root planing is a time-consuming, technique-sensitive, non‑surgical periodontal procedure performed to instrument crown and root surfaces to remove plaque, biofilm, adherent calculus and diseased cementum in pockets caused by migration of the epithelial attachment. The policy exists to guide the plan’s review of medical/dental necessity and contractual coverage: it requires diagnostic documentation (labeled and dated full‑mouth or panoramic radiographs with bitewings and 6‑point periodontal charting within 12 months), specifies clinical thresholds including periodontal pocket depths ≥ 4 mm with bleeding on probing and radiographic bone loss defined as > 1.5 mm apical to the CEJ, mandates administration of local anesthesia by intramucosal injection, and lists primary CDT codes (e.g., D4341, D4342, D4346) and exclusions (for example, gingival diseases without periodontitis).

Evidence Type	Citation
Systematic review/meta-analysis	Smiley CJ et al. J Am Dent Assoc. 2015;146(7):508-24
Textbook reference	Newman and Carranza's Clinical Periodontology, 13th ed., Chapter 64 (2019)

Definitions

Bone lossBone level greater than 1.5 mm apical to the cementoenamel junction (CEJ) as radiographic evidence of alveolar crest loss.

Local anesthesia (policy definition)Administration of anesthesia by intramucosal injection; topical or subgingival anesthetic preparations do not qualify.

Revision History

2019-03-04revision

Policy status marked as Revised; revision history entry reflecting committee revision on 3-4-19.

2019-04-22revision

Policy status marked as Revised; revision history entry reflecting criteria numbering revisions on 4/22/19.

2019-07-23revision

Policy status marked as Revised; revision history entry reflecting verbiage and committee revision on 7/23/19.

2020-05-20revision

Policy status marked as Revised; revision history entry noting annual revision by committee on 5/20/2020.

2020-12-04revision

Policy status marked as Revised; revision history entry noting annual review and committee revision on 12/04/2020.

2021-10-30review

Annual review by committee recorded on 10/30/2021 (last review date).

2022-01-01publishLatest

Publish date of the revised policy: 01/01/2022.

OpenPayer

Dental Clinical Policy

Coverage Summary

Medical Necessity Criteria

Exclusions / Not Covered Conditions

Coding

Provider Actions / Documentation Requirements

Background, Evidence & Definitions

Revision History

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