CurrentBlue Cross Blue Shield - MainePolicy 04-207

Gingival Flap Procedure and Apically Positioned Flap (2022 Policy) PDF. Opens in a new window

Defines clinical indications and coverage criteria for gingival flap procedures (including root planing) and apically positioned flaps for treatment of periodontal disease, including documentation, radiograph, and charting requirements and limits on benefits.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyGingival Flap Procedure and Apically Positioned Flap (2022 Policy) PDF. Opens in a new window

Policy CodePolicy 04-207

Change TypeRevised (annual review)

Effective DateJan 1, 2022

Next Review Date

Key ActionProvide current (within 12 months) dated 6-point periodontal charting showing minimum 5mm pocket depths after non-surgical therapy or maintenance as required for coverage.

SourceLink

POLICY UPDATE CHANGES

Policy marked as Revised with last review date 10/30/2021 and publish date 01/01/2022.

3Primary CDT procedure codes referenced

>=5 mmMinimum pocket depth requirement

2Quadrant limit per date of service

Coverage Summary

Policy Number 04-207 — Subject: Gingival Flap Procedure and Apically Positioned Flap. Coverage stance: covered_with_criteria. Scope: defines clinical indications and documentation, radiograph and charting requirements, and limits on benefits for gingival flap and apically positioned flap procedures. Status: CURRENT (Revised). Effective date: 01/01/2022. Last review date: 10/30/2021.

Medically / Dentally Necessary Criteria

Medically/Dentally Necessary Criteria

Covered when ALL of the following are met:

Non-surgical therapy tried: Treatment is of diseased gingiva after nonsurgical methods, such as root planing and scaling, have been unsuccessful in the removal of subgingival plaque and calculus.
Periodontal charting required after completion of non-surgical periodontal therapy (D4341/D4342) or periodontal maintenance (D4910).
Periodontal charting: Current (within 12 months), dated periodontal charting (6 point periodontal charting) indicating pocket depth recordings of a minimum of 5mm.>= 5 mm
12-month charting
Radiographs: Current pre-treatment radiographs showing periapical area and undistorted image of the alveolar crest.
pre-treatment radiograph requirement
Suprabony pockets indication: Procedure is indicated in the presence of supra-bony pocket depths where there is a need for increased access to root surfaces.
Operative chart notes: Chart notes may be requested to demonstrate a soft tissue flap was reflected/resected or planned to allow debridement of the root surface and removal of granulation tissue.
Osseous recontouring is not accomplished with this procedure.
Natural teeth only: Procedure is for periodontal defects involving natural teeth only.
Procedures performed around implants are not considered.
Laser adjunct: Use of lasers is considered an adjunct and is not eligible for an additional or separate benefit.

ref:

Provider Actions & Documentation Requirements

Documentation Required

Periodontal charting required

Provide current (within 12 months), dated 6-point periodontal charting showing minimum 5 mm pocket depths. Charting is required after completion of non-surgical periodontal therapy (D4341/D4342) or periodontal maintenance (D4910).

Relevant codes: D4341, D4342, D4910
Requirement: Current (within 12 months) 6-point periodontal charting with pocket depths >= 5 mm
Charting must be after non-surgical therapy (scaling/root planing) or periodontal maintenance

Documentation Required

Pre-treatment radiographs required

Provide current pre-treatment radiographs that demonstrate the periapical area and an undistorted image of the alveolar crest prior to performing gingival flap or apically positioned flap procedures.

Pre-treatment radiographs must show the periapical area
Images must include an undistorted view of the alveolar crest

Documentation Required

Operative chart notes may be requested

Operative chart notes may be requested to demonstrate that a soft tissue flap was reflected or resected (or planned) to allow debridement of the root surface and removal of granulation tissue for procedures coded D4240, D4241, D4245.

Relevant codes: D4240, D4241, D4245
Documentation should indicate flap reflected/resected and debridement/granulation tissue removal

Billing Rule

Quadrant limit per date of service

Benefits are limited to two quadrants per date of service for gingival flap and apically positioned flap procedures (codes D4240, D4241, D4245). Exceptions may be allowed on a case-by-case basis.

Relevant codes: D4240, D4241, D4245
Limit: Maximum of two quadrants per date of service
Exceptions: Considered case-by-case

Denial Risk

Not covered for implants or infra-bony/mucogingival cases

Gingival flap procedures (D4240, D4241, D4245) are not considered when performed around implants or for infra-bony pockets or pockets extending below the mucogingival junction; such indications may result in claim denials.

Relevant codes: D4240, D4241, D4245
Not covered: Procedures performed around implants
Not covered: Treatment for infra-bony pockets or pockets extending below the mucogingival junction
Potential outcome: Claims for these indications may be denied

Billing Rule

Laser adjuncts not separately payable

Use of lasers for gingival flap or apically positioned flap procedures is considered adjunctive and is not eligible for an additional or separate benefit; laser adjuncts are not separately payable.

Lasers are adjuncts to treatment and do not qualify for separate reimbursement

Relevant Procedure and Diagnosis Codes

Relevant CDT Procedure Codes (informational)mixed

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
D4341	Periodontal scaling and root planing - four or more teeth per quadrant (referenced as non-surgical therapy)
D4342	Periodontal scaling and root planing - one to three teeth per quadrant (referenced as non-surgical therapy)
D4910	Periodontal maintenance (referenced)

No codes listed

Diagnosis CodesICD-10

IDC-10 CM Diagnoses for Dental Diseases and Conditions: See the current CDT code book for details (no specific ICD-10 codes listed)

Background and Evidence Sources

This policy reviews gingival flap and apically positioned flap procedures to determine dental necessity per accepted standards of dental care. It clarifies these procedures are intended to treat supra-bony pockets after nonsurgical therapy (scaling and root planing) has been unsuccessful and that a soft tissue flap is reflected or resected to allow debridement of the root surface and removal of granulation tissue. The policy specifies these procedures are not intended for osseous recontouring or bone grafting and are not applicable to sites around implants.

Guideline and evidence sources referenced include the American Dental Association Current Dental Terminology (CDT), American Academy of Periodontology guidelines and position papers, and the Proceedings of the World Workshop in Clinical Periodontics (resective procedures).

Generally accepted standards of dental practice: standards based on peer-reviewed dental literature, specialty society recommendations, the views of recognized dentists practicing in the relevant clinical area, and other credible sources; services a prudent dentist provides for evaluating, diagnosing, or treating a dental disease that are appropriate in type, frequency, and extent and are not primarily for convenience or cosmetic purposes.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyGingival Flap Procedure and Apically Positioned Flap (2022 Policy) PDF. Opens in a new window

Policy CodePolicy 04-207

Change TypeRevised (annual review)

Effective DateJan 1, 2022

Next Review Date

Key ActionProvide current (within 12 months) dated 6-point periodontal charting showing minimum 5mm pocket depths after non-surgical therapy or maintenance as required for coverage.

SourceLink

On This Page

OpenPayer

Gingival Flap Procedure and Apically Positioned Flap (2022 Policy) PDF. Opens in a new window

Coverage Summary

Medically / Dentally Necessary Criteria

Not Covered / Contraindications

Benefit Limitations and Quantity Restrictions

Provider Actions & Documentation Requirements

Relevant Procedure and Diagnosis Codes

Background and Evidence Sources

Revision History