CurrentAnthemPolicy 04-901

Periodontal Maintenance Guideline

Guideline describing periodontal maintenance as a nonsurgical, therapeutic continuing-care phase following definitive periodontal therapy, including clinical indications, required documentation/history, and example CDT/ICD-10 codes for informational use. It guides dental professionals on when periodontal maintenance is appropriate and what it entails.

Policy Summary

PayerAnthem

PolicyPeriodontal Maintenance Guideline

Policy CodePolicy 04-901

Change TypeRevised (minor/editorial)

Effective Date

Next Review Date

Key ActionProviders should document prior definitive periodontal therapy with dates and specific treatments rendered to support periodontal maintenance appropriateness.

SourceLink

POLICY UPDATE CHANGES

Added CDT code D4346 and minor editorial refinements to description, clinical indications, criteria (added line #6), and reference; intent unchanged.

6Key clinical points listed

6Referenced major publications

Policy overview

Periodontal Maintenance — Policy 04-901 (Subject: Periodontal Maintenance) describes periodontal maintenance as a lifelong nonsurgical therapeutic continuing-care phase following definitive periodontal (active) therapy. This guideline (Policy 04-901) guides dental professionals on when periodontal maintenance is appropriate and what it entails, including clinical indications, required documentation/history, and example CDT/ICD-10 codes for informational use.

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.

Appropriateness criteria for periodontal maintenance

Appropriateness Criteria for Periodontal Maintenance

Periodontal maintenance is considered appropriate when ALL of the following are met:

History of periodontal therapy and continuous care not exceeding 12 months
Prior history of definitive periodontal therapy with dates and specific treatment rendered
Post-initial therapy evaluations and treatment planning recommendations following completion of periodontal maintenance are considered integral components of this procedure
Exclusion criterion: A periodontal maintenance procedure is not appropriate when there is no history of periodontal disease requiring definitive periodontal treatment
Exclusion criterion
Current American Academy of Periodontology (AAP) and American Dental Association (ADA) guidelines require a periodontal diagnosis including staging and grading

Documentation Required

Document prior definitive periodontal therapy

Document prior definitive periodontal therapy including the dates and the specific treatments rendered to support that periodontal maintenance is appropriate. Include relevant CDT codes when charting the prior procedures.

D4341
D4342
D4346
D4910

Documentation Required

Diagnosis staging and grading required

Include a periodontal diagnosis with staging and grading in the record in accordance with current American Academy of Periodontology (AAP) and American Dental Association (ADA) guidelines to meet documentation criteria for periodontal maintenance.

Example CDT and ICD-10 codes (informational)

CDT codes (informational list)mixed

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 evaluation
D4381	Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
D4910	Periodontal maintenance
D4999	Unspecified periodontal procedure, by report

ICD-10-CM diagnoses (informational)ICD-10

See CDT code book

ICD-10 CM Diagnoses for Dental Diseases and Conditions: see current CDT code book for details

The listed CDT and ICD-10 codes are provided for informational purposes only; inclusion or exclusion of a procedure, diagnosis or device code does not constitute or imply coverage or reimbursement. Coding and billing should follow the current CDT code book and applicable payer rules and member contract benefits in effect at the time of service.

Supporting evidence and definition

The policy references American Academy of Periodontology (AAP) and American Dental Association (ADA) statements and position papers (2000–2006) supporting periodontal maintenance as a therapeutic continuing-care phase after active periodontal therapy. These references include the AAP Parameter on Periodontal Maintenance (2000), the AAP position paper on periodontal maintenance (2003), and the AAP statement on local delivery antimicrobials (2006), which the policy cites as the basis for defining periodontal maintenance as ongoing therapeutic care.

Definition

DefinitionPeriodontal maintenance: A nonsurgical therapeutic continuing-care procedure following definitive periodontal therapy that includes instrumentation of tooth crown and root structures to remove etiologic factors and monitor periodontal conditions.