CurrentAnthemPolicy 04-207

Gingival flap procedure and apically positioned flap

Policy governing dental gingival flap procedures, including root planing and apically positioned flap, describing clinical indications, documentation and coding requirements that affect dental providers and benefit determinations under Anthem plans.

Policy Summary

PayerAnthem

PolicyGingival flap procedure and apically positioned flap

Policy CodePolicy 04-207

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review Date

Key ActionObtain current (within 12 months) 6-point periodontal charting showing pocket depths ≥5 mm and pre-treatment radiographs for benefit determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D4240/D4241/D4245CDT codes listed

2 quadrantsBenefit limit

6-pointCharting required

12 moRadiograph window

Coverage Criteria

Medically necessary / covered criteria

Policy Summary

PayerAnthem

PolicyGingival flap procedure and apically positioned flap

Policy CodePolicy 04-207

Change TypeNo material changes

Effective DateJan 1, 2022

Next Review Date

Key ActionObtain current (within 12 months) 6-point periodontal charting showing pocket depths ≥5 mm and pre-treatment radiographs for benefit determination.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Primary coverage criteria: 1) Non-surgical methods such as scaling and root planing have been unsuccessful in removal of subgingival plaque and calculus.

Required: periodontal charting after completion of non-surgical periodontal therapy (D4341/D4342) or periodontal maintenance (D4910) is required.

2) Procedure indicated for supra-bony pocket depths where increased access to root surfaces is needed (osseous recontouring and bone grafting are not required).

3) Current (within 12 months) dated 6-point periodontal charting indicating pocket depth recordings minimum of 5 mm.>= 5 mm

4) Current pre-treatment radiographs showing the periapical area and an undistorted image of the alveolar crest.

5) Chart notes may be requested to demonstrate that soft tissue was reflected or resected to allow debridement of the root surface and removal of granulation tissue.

6) Procedure does not accomplish osseous recontouring (i.e., intended for soft-tissue access only).

7) Treatment applies to periodontal defects involving natural teeth only (procedures performed around implants are not considered).

8) Use of lasers is considered an adjunct and is not eligible for an additional or separate benefit for benefit determination.

9) Benefits are limited to two quadrants per date of service; exceptions may be allowed.

Documentation described above is required for benefit determination.

Not eligible when any of the following are present

Procedures performed for infra-bony pockets are not considered (not medically necessary under this guideline).
Procedures performed for pockets extending below the mucogingival junction are not considered (not medically necessary).
Procedures performed for minimal amounts of attached keratinized tissue are not considered.

Gingival flap procedures will not be considered when performed around implants. Additional exclusions include procedures intended for the treatment of infra-bony pockets and situations with only minimal amounts of attached keratinized tissue. These exclusions mean that benefits are not available for flap procedures when the defect is primarily osseous in nature or when the procedure is being performed on or immediately adjacent to dental implants.

Coding and Clinical Thresholds

Included CDT CodesCDT

D4240	Gingival Flap Procedure including root planing four or more teeth
D4241	Gingival Flap Procedure including root planing one to three teeth
D4245	Apical Positioned Flap

Diagnosis codesICD-10

ICD-10-CM

Diagnoses for dental diseases and conditions (see current CDT/ICD code book)

inv-06: Periodontal pocket depth — clinical threshold value

Minimum pocket depth>= 5 mm (documented on current 6‑point periodontal charting within 12 months)

Charting requirementDated 6‑point periodontal charting within 12 months showing pocket depths

Post‑nonsurgical verificationPeriodontal charting after completion of non‑surgical therapy (D4341/D4342) or periodontal maintenance (D4910) is required

Provider Actions, Documentation & Authorization

Prior Authorization

Prior authorization / benefit determination — 2-quadrant limit

Benefits are limited to two quadrants per date of service; exceptions may be allowed. Documentation described in the policy is required for benefit determination.

Applicable CDT codes: D4240, D4241, D4245 must be submitted for review.
Provide required documentation (periodontal charting, pre-treatment radiographs, and chart notes) to support benefit determination.

Step Therapy

Required prior non-surgical therapy — scaling and root planing first

Procedure is indicated only after non-surgical methods such as scaling and root planing have been unsuccessful in removing subgingival plaque and calculus.

Periodontal charting after completion of non-surgical periodontal therapy (D4341/D4342) or periodontal maintenance (D4910) is required.

Documentation Required

Required documentation — charting, radiographs, and chart notes

Submit current (within 12 months) dated 6-point periodontal charting showing pocket depths with a minimum of 5 mm, current pre-treatment radiographs showing the periapical area and an undistorted image of the alveolar crest, and chart notes demonstrating soft tissue was reflected/resected to allow debridement and removal of granulation tissue when requested.

Periodontal charting must be dated and within 12 months of the procedure.
Pre-treatment radiographs must show the periapical area and an undistorted alveolar crest.
Chart notes documenting the soft-tissue reflection/resection and debridement may be requested.
Periodontal charting after non-surgical therapy (D4341/D4342) or periodontal maintenance (D4910) is required.

Denial Risk

Conditions triggering non-coverage — implants, infra-bony, mucogingival junction

Gingival flap procedures are not considered when performed around implants; procedures for infra-bony pockets or pockets extending below the mucogingival junction are not covered under this guideline.

Procedures performed for treatment of infra-bony pockets are not performed/covered.
Procedures for pockets extending below the mucogingival junction are not performed/covered.
Not applicable for areas with minimal amounts of attached keratinized tissue.

Background

The gingival flap procedure and the apically positioned flap are soft-tissue surgical techniques in which gingival tissue is reflected or resected to allow debridement of the root surface and removal of granulation tissue. The apically positioned flap repositions the tissue apically to improve access to root surfaces when non-surgical therapy (for example, scaling and root planing) has been unsuccessful in removing subgingival plaque and calculus. These procedures are intended for supra-bony pocket situations where increased access to root surfaces is required and where osseous recontouring is not accomplished by the flap procedure.

Definitions

inv-12: Gingival flap procedure / Apically positioned flap — definition and procedural summary

DefinitionSoft tissue is reflected or resected to allow debridement of the root surface and removal of granulation tissue; an apically positioned flap repositions tissue apically to improve access to root surfaces.

IndicationUsed when non‑surgical methods (scaling and root planing) have been unsuccessful in removing subgingival plaque and calculus and for supra‑bony pockets where increased access to root surfaces is needed.

LimitationsNot intended when osseous recontouring or bone grafting are required; applies to periodontal defects involving natural teeth only.

AdjunctsUse of lasers is considered an adjunct and is not eligible for an additional or separate benefit.