CurrentBlue Cross Blue Shield - MainePolicy 01 -101

Prophylaxis (2021 Policy) PDF. Opens in a new window

Defines clinical indications, risk assessment factors, and relevant procedure codes for dental prophylaxis, full mouth debridement, and related preventive dental procedures for children and adults; intended as a clinical guideline to inform utilization review and determination of medical/dental necessity under plan contracts.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProphylaxis (2021 Policy) PDF. Opens in a new window

Policy CodePolicy 01 -101

Change TypeAnnual Revision (12/4/20)

Effective DateJan 1, 2021

Next Review Date

Key ActionDocument presence of plaque/stain/calculus, factors influencing plaque retention, oral hygiene status, and risk assessment elements to support frequency of prophylaxis and any interval less than six months.

SourceLink

POLICY UPDATE CHANGES

Policy revised with annual revision dated 12/4/20.

7Risk assessment elements listed

6Core prophylaxis indications listed

7CDT codes enumerated

Coverage summary

This guideline defines clinical indications for dental prophylaxis (a routine preventive procedure to remove supragingival plaque, stain, and calculus and to observe hard and soft tissues) and full mouth debridement (preliminary treatment when plaque/calculus interfere with a comprehensive oral evaluation). It is intended as a clinical guideline to inform utilization review and determination of medical/dental necessity under plan contracts. Coverage and reimbursement depend on the member's contract benefits and inclusion of codes in the guideline is informational and does not guarantee coverage.

Medical necessity and clinical criteria

Indications for dental prophylaxis

Dental prophylaxis is indicated when ALL of the following clinical findings/conditions apply:

ALL of the following

Presence of plaque, stain, or calculus
Presence of factors that influence the build-up and retention of plaque
Improper oral hygiene
Maintenance of gingival health

Full mouth debridement

Full mouth debridement is appropriate when:

ALL of the following

Plaque and calculus interfere with the ability of the dentist to perform a comprehensive oral evaluation

Risk assessment elements

Risk assessments typically include the following elements (any may contribute to decision to provide prophylaxis more frequently than every six months):

ANY of the following

Medical and dental history including any medications
Age
Compliance with treatment recommendations
Previous and current evidence of caries
Previous and current periodontal health evaluation

Relevant codes (informational)

Applicable CDT codes (informational)mixed

D1110	Prophylaxis - adult
D1330	Oral hygiene instructions
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 exam
D4355	Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit
D4910	Periodontal maintenance

ICD-10-CM diagnosesICD-10

See the current CDT code book for applicable dental disease and condition diagnosis codes

Provider requirements and authorization notes

Documentation Required

Document indications and risk assessment

Document presence of plaque, stain, or calculus, factors influencing plaque retention, oral hygiene status, and risk assessment elements (medical/dental history, age, compliance, caries history, periodontal evaluation, family history, gingivitis, calculus, staining, local factors) to support frequency of prophylaxis and any interval less than six months.

Presence of plaque, stain, or calculus
Factors influencing plaque build-up and retention
Oral hygiene status/compliance
Medical and dental history including medications
Age
Previous and current evidence of caries
Previous and current periodontal health evaluation
Family or patient history of periodontal disease
Presence of gingivitis (bleeding)
Presence of calculus
Presence of external tooth staining
Local factors influencing plaque retention

Denial Risk

Verify member benefits

Determine member coverage based on the member's contract benefits; inclusion of codes in this guideline is informational and does not guarantee coverage or reimbursement.

Code lists are informational only and do not guarantee coverage or reimbursement.

Definitions and background

This clinical guideline focuses on routine dental prophylaxis — removal of supragingival plaque, stain, and calculus (may use ultrasonic or hand scaling) and observation of hard and soft tissues — and on full mouth debridement when plaque/calculus prevent a comprehensive oral evaluation. Services determined to be medically or dentally necessary must still be checked against the member's contract benefits to determine coverage.

Term	Definition
Dental prophylaxis
A routine preventative procedure performed to remove supragingival plaque, stain, and calculus from teeth surfaces, may utilize scaling (above the gingival sulcus) with ultrasonic or hand instruments, and includes observation of hard and soft tissues.
Full mouth debridement
Preliminary treatment required when plaque and calculus interfere with the ability to perform a comprehensive oral evaluation; enables subsequent comprehensive exam and diagnosis.
Generally accepted standards of dental practice
Standards based on credible scientific evidence, specialty society recommendations, views of recognized dentists, and other relevant credible sources.