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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield - Maine periodontal coverag…
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    CurrentBlue Cross Blue Shield - MainePolicy 04-208

    Periodontal Surgical Procedures, miscellaneous

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    Policy governing coverage and documentation requirements for miscellaneous periodontal surgical procedures (including anatomical crown exposure, surgical revision, and mesial/distal wedge) for Blue Cross Blue Shield - Maine members.

    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyPeriodontal Surgical Procedures, miscellaneous
    Policy CodePolicy 04-208
    Change TypeNo material changes
    Effective Date
    Last ReviewOct 28, 2024
    Next Review DateJan 1, 2025
    Key ActionProvide labeled and dated periodontal charting and diagnostic radiographs within 12 months and confirm completion of non-surgical therapy with a minimum 4-week healing period prior to mesial/distal wedge procedures.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2

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    Quadrant limit
    5mmMinimum pocket depth
    D4230/D4231/D4268/D4274Example CDT codes
    YesPrior therapy required

    Coverage Criteria

    General medical necessity for miscellaneous periodontal surgical procedures

    Covered when ALL of the following are met

    Primary clinical requirements

    • Procedure-specific indications: Anatomical crown exposure (D4230/D4231): indicated in an otherwise periodontally healthy area to remove enlarged gingival tissue and supporting bone to restore anatomic gingival relationship, allow proper restoration contour, or manage a fractured tooth extending subgingivally; Surgical revision (D4268): indicated to refine results of a previously provided surgical procedure and to modify irregular hard or soft tissue contours; Mesial/Distal wedge (D4274): indicated for the presence of active periodontal disease with moderate to deep probing depths (>5 mm) on a surface adjacent to an edentulous/terminal tooth area, or when increased access to the root surface is needed after unsuccessful non-surgical therapy.
    • Documentation, timing, and limits: Provide labeled and dated periodontal charting and diagnostic-quality radiographs within 12 months (post-treatment charting for surgical revision; pretreatment charting for mesial/distal wedge). Mesial/distal wedge requires completion of initial periodontal therapy with a minimum 4-week healing period prior to surgery. Pocket depth recordings must be >= 5 mm. Procedures are limited to natural teeth and to two quadrants per date of service.>= 5 mm

      Completion of non-surgical therapy required for mesial/distal wedge with >=4-week healing

    Coverage excludes procedures performed solely for cosmetic/aesthetic purposes. Patients with an uncontrolled underlying medical condition are not eligible for benefit for these procedures. Correction of altered passive eruption is specifically not indicated. Additionally, second‑stage implant surgery, membrane removal, or retreatment of a failing soft tissue graft are not indicated as surgical revision procedures and are therefore not covered when billed as such.

    Operationally, benefits may be denied when procedures are submitted in conjunction with or in preparation for a non‑covered or denied service. Surgical revision procedures submitted within the plan frequency limitations of the initial surgical procedure by the same dentist/dental office are disallowed; when submitted within those frequency limitations by a different dentist/dental office they are denied. Services performed in the same anatomical area on the same date of service are considered inclusive and may not be separately benefited.

    Coding and Clinical Thresholds

    CDT example codes listedCPT
    D4230Anatomical Crown Exposure four or more contiguous teeth
    D4231Anatomical Crown Exposure one to three contiguous teeth
    D4268Surgical Revision Procedure per tooth
    D4274Mesial/Distal Wedge Procedure single tooth
    Periodontal pocket depth — minimum recorded depth threshold
    Minimum recorded periodontal pocket depth>= 5 mm
    Recording timeframe for chartingLabeled and dated 6‑point periodontal pocket depth charting within 12 months
    Tooth limitationsLimited to natural teeth only
    Quadrant limit per date of serviceLimited to two quadrants per date of service

    Provider Actions, Documentation, and Billing Notes

    Prior Authorization

    Prior authorization / Frequency review

    Prior authorization and frequency review may be required. Procedures submitted within the plan frequency limitations of an initial surgical procedure are disallowed when performed by the same dentist/dental office and denied when performed by a different dentist/dental office. Periodontal surgical procedures are limited to two quadrants per date of service; exceptions require case-by-case review.

    • When procedure submitted within plan frequency limits by same dentist/dental office → DISALLOWED
    • When procedure submitted within plan frequency limits by different dentist/dental office → DENIED
    • Limit: Periodontal surgical procedures limited to two quadrants per date of service; exceptions reviewed case-by-case
    Documentation Required

    Clinical data and coding notes

    Clinical documentation must support the medical necessity and coding. Include labeled and dated periodontal charting and current diagnostic-quality radiographs (within 12 months). Pocket depth recordings must be 5 mm or greater and limited to natural teeth only. Submit the CDT codes as billed (examples listed) and relevant ICD-10 diagnoses.

    Background

    Miscellaneous periodontal surgical procedures are indicated when periodontal health cannot be achieved or maintained non‑surgically. Typical indications include elimination of periodontal pockets, recontouring alveolar bone, exposing or lengthening a clinical crown to allow restoration contour or manage subgingival tooth fracture, and refinement of previously performed surgical results. Mesial/distal wedge procedures are used to improve access and reduce pocket depths adjacent to an edentulous/terminal tooth area when non‑surgical therapy has been insufficient.

    Definitions

    Surgical revision procedure — definition and purpose
    DefinitionProcedure used to refine results of a previously performed surgical procedure by modifying irregular contours of hard and/or soft tissues
    Clinical intentModify irregular hard and/or soft tissue contours to improve surgical outcomes
    Documentation requirementProvide labeled and dated (within 12 months) post‑treatment 6‑point periodontal pocket depth charting
    Coverage constraintServices submitted within plan frequency limitations of the initial surgical procedure may be disallowed or denied
    Mesial/Distal Wedge Procedure — definition and procedural intent
    DefinitionProcedure performed for a single tooth in an edentulous area adjacent to a tooth to remove tissue to gain access for debridement, aid cleaning of the mesial or distal area, and reduce pocket depths
    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyPeriodontal Surgical Procedures, miscellaneous
    Policy CodePolicy 04-208
    Change TypeNo material changes
    Effective Date
    Last ReviewOct 28, 2024
    Next Review DateJan 1, 2025
    Key ActionProvide labeled and dated periodontal charting and diagnostic radiographs within 12 months and confirm completion of non-surgical therapy with a minimum 4-week healing period prior to mesial/distal wedge procedures.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Clinical ThresholdsProvider Actions, Documentation, and Billing NotesBackgroundDefinitions
    • Labeled and dated post-treatment 6‑point periodontal pocket depth charting (within 12 months) for surgical revision procedures
    • Labeled and dated pretreatment 6‑point periodontal pocket depth charting (within 12 months) for distal wedge procedures
    • Current (within 12 months), diagnostic-quality, dated pretreatment radiographic images showing horizontal and/or vertical osseous defects
    • Limited to periodontal pocket depth recordings >= 5 mm
    • Limited to natural teeth only
    • Include CDT codes (e.g., D4230, D4231, D4268, D4274) and applicable ICD-10 CM diagnoses
    Documentation Required

    Required prior non-surgical therapy

    Mesial/distal wedge procedures require completion of initial non-surgical periodontal therapy (e.g., scaling and root planing) with a minimum 4‑week healing interval prior to any surgical treatment to allow for proper healing and assessment of periodontal status.

    • Completion of initial periodontal therapy (scaling and root planing) required
    • Allow minimum 4 weeks between completion of non-surgical therapy and surgical treatment
    IndicationsActive periodontal disease with moderate to deep probing depths (>5 mm) adjacent to an edentulous/terminal tooth area or when non‑surgical attempts have been unsuccessful
    Prior therapy requirementCompletion of initial periodontal therapy (e.g., scaling and root planing) with a minimum 4‑week healing period prior to surgery
    Documentation requirementProvide labeled and dated (within 12 months) pretreatment 6‑point periodontal pocket depth charting and diagnostic radiographs
    Anatomical crown exposure (D4230/D4231) — definition and clinical intent
    DefinitionSurgical exposure of the crown to remove enlarged gingival tissue and supporting bone to restore anatomic gingival relationship
    Clinical intentsAllow proper contour of restoration or manage a fractured tooth that extends subgingivally in an otherwise periodontally healthy area
    Anatomic contextPerformed in an otherwise periodontally healthy area to reestablish correct gingival relationships