CurrentBlue Cross Blue Shield - MainePolicy 04-901

Periodontal Maintenance (2023 Policy) PDF. Opens in a new window

Defines clinical indications, documentation and coding guidance for periodontal maintenance as a therapeutic, nonsurgical continuing care procedure following definitive periodontal treatment; provides CDT codes for informational use and references. It is guidance for applying dental benefit medical necessity and appropriateness determinations.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyPeriodontal Maintenance (2023 Policy) PDF. Opens in a new window

Policy CodePolicy 04-901

Change TypeNo material change

Effective DateJan 1, 2023

Next Review Date

Key ActionProvide prior history of definitive periodontal therapy with dates and specific treatments rendered to support necessity of periodontal maintenance.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes.

5Key Clinical Requirements

5CDT Codes Listed

Coverage Summary

Scope: Defines clinical indications, documentation and coding guidance for periodontal maintenance as a therapeutic, nonsurgical continuing care procedure following definitive periodontal treatment; provides CDT codes for informational use and references. It is guidance for applying dental benefit medical necessity and appropriateness determinations.

Background: Periodontal maintenance is a lifelong nonsurgical therapeutic procedure following active periodontal therapy intended to maintain periodontal health and reduce etiologic factors. The policy interprets generally accepted standards of dental practice and emphasizes documentation of prior definitive therapy and continuous care. Effective date: 2023-01-01; Last review date: 2022-10-28.

Medical / Dental Necessity Criteria

Medically/Dentally Necessary Periodontal Maintenance

Covered when ALL of the following are met:

ALL of the following

Patient has history of periodontal therapy and continuous care not exceeding 12 months
There is prior history of definitive periodontal therapy with dates and specific treatment rendered
Procedure is being used as continuing therapeutic maintenance following therapeutic periodontal treatment (not prophylactic)
Procedure provides treatment and continuing care of patients with a history of and ongoing periodontal disease or following implant placement
Procedure involves instrumentation of tooth crown and root structures (hand instrumentation) to remove etiological factors such as plaque, biofilm, adherent calculus deposits, and diseased cementum
Post-initial therapy evaluations and treatment planning recommendations following completion of periodontal maintenance are considered integral components of this procedure
A periodontal maintenance procedure is NOT appropriate when there is no history of periodontal disease requiring definitive periodontal treatment
This is an exclusion criterion

Coding

CDT Codes (informational)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
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 (refer to CDT book)ICD-10

No codes listed

Billing Rule

Coding informational guidance

CDT codes listed are for informational purposes only; inclusion or exclusion does not guarantee member coverage—verify member contract benefits at time of service.

D4341
D4342
D4381
D4910
D4999

Provider Actions & Documentation Requirements

Documentation Required

Document history of definitive periodontal therapy

Provide prior history of definitive periodontal therapy with dates and specific treatments rendered to support necessity of periodontal maintenance.

Documentation Required

Continuous care interval documentation

Document history of periodontal therapy and continuous care not exceeding 12 months to justify ongoing periodontal maintenance.

Documentation Required

Letter of medical necessity for LACA

Submit a letter of medical necessity when locally administered chemotherapeutic agents (LACA) are used as part of periodontal maintenance.

D4381

Denial Risk

Inappropriate without prior definitive periodontal treatment

Claims for periodontal maintenance may be denied when there is no history of periodontal disease requiring definitive periodontal treatment.

D4910

Background & Definitions

Periodontal maintenance is described as a lifelong nonsurgical therapeutic continuing care procedure following periodontal therapy to remove etiologic factors and monitor periodontal disease; it is therapeutic (not prophylactic) and involves instrumentation of tooth crown and root structures, typically hand instrumentation.

The policy emphasizes documentation: provide history of definitive periodontal therapy with dates and specific treatments rendered, document history of periodontal therapy and continuous care not exceeding 12 months, and submit a letter of medical necessity when locally administered chemotherapeutic agents (LACA) are used.

Term	Definition
Periodontal maintenance
A nonsurgical therapeutic continuing care procedure following periodontal therapy intended to remove etiologic factors and monitor periodontal disease for the life of the dentition or implant placement.
Generally accepted standards of dental practice
Standards based on credible scientific evidence, specialty society recommendations, views of recognized dentists, and other credible sources.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyPeriodontal Maintenance (2023 Policy) PDF. Opens in a new window

Policy CodePolicy 04-901

Change TypeNo material change

Effective DateJan 1, 2023

Next Review Date

Key ActionProvide prior history of definitive periodontal therapy with dates and specific treatments rendered to support necessity of periodontal maintenance.

SourceLink

On This Page

OpenPayer

Periodontal Maintenance (2023 Policy) PDF. Opens in a new window

Coverage Summary

Medical / Dental Necessity Criteria

Coding

Provider Actions & Documentation Requirements

Background & Definitions

Revision History