CurrentAnthemPolicy 04-205

Osseous Surgery (Periodontal)

Policy governing when osseous surgery for periodontal disease (including peri-implant defects) is considered appropriate under Anthem dental benefits; applies to providers submitting dental benefit requests for Anthem members. It describes clinical criteria, documentation, and benefit limitations that affect coverage decisions.

Policy Summary

PayerAnthem

PolicyOsseous Surgery (Periodontal)

Policy CodePolicy 04-205

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review Date

Key ActionObtain prior authorization when required and submit radiographs plus current 6‑point periodontal charting demonstrating ≥5 mm pockets and bleeding on probing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 quadrantsbenefit limit per date of service

one procedurelimit per tooth or multiple teeth in same quadrant

>=5 mmminimum pocket depth (probing)

12 monthscharting recency

4 weekshealing interval after non-surgical therapy

Coverage Criteria

Appropriate when ALL of the following are met

Osseous surgery procedures are considered appropriate when the following conditions are satisfied:

Completed initial therapy: Completion of initial periodontal therapy (e.g., scaling and root planing) with a minimum 4-week healing period prior to surgical treatmentminimum 4 weeks

chunk 5

Documented bone loss: Clinical and diagnostic radiographic images demonstrating horizontal and/or vertical osseous defectsradiographic or clinical

chunk 5

Periodontal charting: Current (within 12 months) dated 6-point periodontal charting indicating pocket depths of at least 5 mm

Policy Summary

PayerAnthem

PolicyOsseous Surgery (Periodontal)

Policy CodePolicy 04-205

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review Date

Key ActionObtain prior authorization when required and submit radiographs plus current 6‑point periodontal charting demonstrating ≥5 mm pockets and bleeding on probing.

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.

Coding and Procedural Limits

Included CDT codesCDT

D4260	Osseous surgery (including elevation of a full thickness and closure) four or more contiguous teeth or tooth bounded spaces per quadrant flap
D4261	Osseous surgery (including elevation of a full thickness and closure) one to three contiguous teeth or tooth bounded spaces per quadrant flap
D6101	Debridement and osseous recontouring of peri-implant defect or defects surrounding a single implant, surface cleaning of the exposed implant surfaces, including flap entry and closure
D6102	Debridement and osseous recontouring of a peri-implant defect or defects surrounding a single implant, and includes surface cleaning of the exposed implant surfaces, including flap entry and closure

inv-05: Minimum periodontal probing depth

Minimum periodontal probing depth>= 5 mm

ContextPocket depths must be documented on current (within 12 months) 6‑point periodontal charting and accompanied by spontaneous bleeding or bleeding on probing.

Applies toNatural teeth and dental implants when osseous defects are documented.

inv-06: Periodontal charting recency

Required recency for periodontal chartingWithin 12 months (current, dated 6‑point periodontal charting)

Charting standard6‑point periodontal charting as described by AAP and ADA must be used to document pocket depths.

PurposeUsed to demonstrate pocket depths of at least 5 mm for surgical appropriateness.

Provider Actions and Documentation Requirements

Prior Authorization

Prior authorization/documentation may be required

Prior authorization or review may be required per the member's plan contract. When submitting for review, include the required supporting documentation (radiographs and periodontal charting) as described in the policy.

Include clinical and diagnostic radiographic images demonstrating osseous defects.
Include current (within 12 months) dated 6-point periodontal charting.

Step Therapy

Complete initial non-surgical therapy and wait minimum 4 weeks

Complete initial non-surgical periodontal therapy (for example, scaling and root planing) and allow a minimum four-week healing period prior to considering osseous surgery.

Minimum 4-week healing interval after non-surgical therapy to permit assessment of treatment response.

Documentation Required

Required clinical and radiographic documentation

Submit clinical and diagnostic radiographic images that demonstrate horizontal and/or vertical osseous defects, and provide current (within 12 months) dated 6‑point periodontal charting showing pocket depths; if radiographs are non‑demonstrative, supply a detailed narrative.

Radiographs showing horizontal and/or vertical osseous defects.
Current (within 12 months) dated 6‑point periodontal charting with pocket depth recordings.
When radiographs are not demonstrative, include a narrative describing periodontal case type, percentage of bone loss, measured furcation involvement, and vertical defect description.

Denial Risk

Related services tied to non‑covered/denied service will be non‑covered/denied

Any services performed in conjunction with or in preparation for a non‑covered or denied service will also be non‑covered or denied.

Verify member contract benefits; related procedures tied to a non‑covered/denied service will not be covered.

Background

Osseous surgery is a periodontal surgical procedure intended to correct osseous defects (horizontal and/or vertical) that result from periodontal disease. Typical procedures include elevation of a full‑thickness flap, osseous recontouring, and closure, and the policy treats similar procedures around dental implants the same as for natural teeth. Indications for osseous surgery require documented bone defects on clinical or radiographic exam plus supportive periodontal measurements and findings.

For coverage consideration, the policy requires completion of initial non‑surgical periodontal therapy (for example, scaling and root planing) with a minimum healing interval of 4 weeks, submission of clinical and diagnostic radiographs demonstrating osseous defects, and current (within 12 months) dated 6‑point periodontal charting showing pocket depths of at least 5 mm and evidence of bleeding on probing when applicable. When radiographs are non‑diagnostic, a detailed narrative describing case type, percent bone loss, furcation involvement, and vertical defect may be requested.

Definitions

inv-12: Osseous surgery — definition (procedural description)

DefinitionSurgical procedures to correct osseous defects in periodontal disease that typically include elevation of a full‑thickness flap, osseous recontouring (resection or reshaping of bone), and closure; may include debridement and osseous recontouring around dental implants with flap entry and closure.

IndicationsPerformed to treat documented horizontal or vertical bone defects associated with periodontal disease when pocket depth and bleeding criteria are met.

ScopeIncludes procedures around natural teeth and implants; post‑operative management and surgical re‑entry frequency are subject to group contract limits.

inv-13: 6-point periodontal charting — definition and use

DefinitionDated periodontal charting that records six sites per tooth (6‑point charting) as described by the AAP and ADA and used to document pocket depths for surgical appropriateness.

Required informationMust be current (within 12 months) and demonstrate pocket depths of at least 5 mm plus spontaneous bleeding or bleeding on probing to support osseous surgery.

When radiographs non‑diagnosticIf radiographic images are not demonstrative, supplemental narrative describing case type, percent bone loss, furcation involvement, and vertical defect may be requested.