CurrentBlue Cross Blue Shield - MainePolicy 04-901

Periodontal Maintenance (2025 Policy) PDF. Opens in a new window

Defines clinical indications and criteria for periodontal maintenance as a nonsurgical, therapeutic continuing-care procedure following definitive periodontal therapy; includes applicable CDT codes for informational purposes. Governs when periodontal maintenance is considered appropriate and what documentation/history is required.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyPeriodontal Maintenance (2025 Policy) PDF. Opens in a new window

Policy CodePolicy 04-901

Change TypeMinor editorial refinements

Effective DateJan 1, 2025

Next Review Date

Key ActionProviders must document prior history of definitive periodontal therapy including dates and specific treatments rendered to support appropriateness of periodontal maintenance.

SourceLink

POLICY UPDATE CHANGES

Minor editorial refinements to description, clinical indications, criteria (added line #6), and reference; intent unchanged.

1Primary CPT/CDT maintenance code (D4910)

5Referenced CDT codes

12 monthsMaximum continuous care interval documented

Coverage Summary

Defines clinical indications and criteria for periodontal maintenance as a nonsurgical, therapeutic continuing-care procedure provided following definitive periodontal (therapeutic) treatment. The procedure is intended to maintain periodontal health for the life of the dentition or any implant and to minimize recurrence and progression of periodontal disease.

The policy governs when periodontal maintenance is considered appropriate and what documentation and history are required (for example, prior definitive periodontal therapy with dates and treatments, and a periodontal diagnosis including staging and grading per current AAP and ADA guidelines). Effective date: 2025-01-01. Last review date: 2024-10-28.

Medically Necessary / Appropriate Criteria

Medically Necessary / Appropriate Criteria for Periodontal Maintenance

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

ALL of the following

Clinical history and interval: History of periodontal therapy and continuous care not exceeding 12 monthsnot exceeding 12 months
From criteria requiring continuous care interval
Prior definitive therapy documentation: Prior history of definitive periodontal therapy with dates and specific treatment rendered
Providers must document prior definitive periodontal therapy including dates and treatments
Post-therapy evaluations: Post-initial therapy evaluations and treatment planning recommendations following completion of periodontal maintenance are considered integral components of this procedure
Monitoring and treatment planning are integral components
Diagnosis requirement: A periodontal diagnosis including staging and grading per current AAP and ADA guidelines
Per AAP and ADA guideline requirement
Therapeutic indication: Procedure is for patients with a history of and ongoing periodontal disease (therapeutic rather than prophylactic; continuing treatment for patients with diagnosis of periodontal disease)
Therapeutic objective is maintenance of periodontal health after active therapy
Procedure description: Procedure involves instrumentation of tooth crown and root structures to remove etiologic factors (plaque, biofilm, adherent calculus, diseased cementum) and may include hand instrumentation
Describes scope and techniques of periodontal maintenance
Monitoring during maintenance of periodontal disease and conditions (e.g., probing depth changes, bleeding on probing, bone loss changes)
Ongoing monitoring parameters to be documented
Exclusion condition: A periodontal maintenance procedure is not appropriate when there is no history of periodontal disease requiring definitive periodontal treatment
Exclusion: no prior periodontal disease requiring definitive treatment

Exclusion branch (duplicate top-level for clarity): Exclusion condition: not appropriate when no history of periodontal disease requiring definitive periodontal treatment

Reflects explicit exclusion in criteria list

Documentation & Provider Requirements

Documentation Required

Document prior definitive periodontal therapy

Providers must document prior history of definitive periodontal therapy including dates and specific treatments rendered to support appropriateness of periodontal maintenance.

D4341
D4342
D4381
D4910
D4999

Documentation Required

Provide periodontal diagnosis with staging and grading

Providers must include a periodontal diagnosis including staging and grading in accordance with current AAP and ADA guidelines.

Use current AAP and ADA guidelines

Documentation Required

Ongoing monitoring documentation

Providers should document monitoring parameters (probing depths, bleeding on probing, bone loss changes) and post-initial therapy evaluations and treatment planning recommendations as integral components of the procedure.

probing depths, bleeding on probing, bone loss changes; post-initial therapy evaluations and treatment planning recommendations

Background, Evidence & Definitions

Periodontal maintenance is a nonsurgical continuing-care treatment performed after active (therapeutic) periodontal therapy to maintain the periodontal health status attained by definitive treatment. It is therapeutic in purpose and intended to continue for the life of the dentition or any implant placement.

Unlike prophylaxis, periodontal maintenance is a therapeutic, rather than preventive, procedure for patients with a history of and ongoing periodontal disease. It involves instrumentation of crown and root structures to remove etiologic factors (plaque, biofilm, adherent calculus, diseased cementum), may include hand instrumentation, and includes monitoring of disease indicators such as probing depths, bleeding on probing, and bone loss changes.

AAP Parameter on Periodontal Maintenance (J Periodontol): 2000;71:849-850.

AAP Position Paper - Periodontal Maintenance (J Periodontol): 2003;74(9):1395-1401.

Periodontal maintenance: A nonsurgical therapeutic procedure following definitive periodontal treatment involving instrumentation of crown and root to remove plaque, biofilm, calculus and diseased cementum and ongoing monitoring to prevent recurrence/progression of periodontal disease.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyPeriodontal Maintenance (2025 Policy) PDF. Opens in a new window

Policy CodePolicy 04-901

Change TypeMinor editorial refinements

Effective DateJan 1, 2025

Next Review Date

Key ActionProviders must document prior history of definitive periodontal therapy including dates and specific treatments rendered to support appropriateness of periodontal maintenance.

SourceLink

On This Page

OpenPayer

Periodontal Maintenance (2025 Policy) PDF. Opens in a new window

Coverage Summary

Medically Necessary / Appropriate Criteria

Coding (CDT / ICD-10)

Documentation & Provider Requirements

Background, Evidence & Definitions

Revision History

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