CurrentBlue Cross Blue Shield - MainePolicy 04-208

Periodontal Surgical Procedures, miscellaneous

Defines medical necessity criteria, documentation requirements, and benefit determinations for miscellaneous periodontal surgical procedures (e.g., anatomical crown exposure, surgical revision, 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 change

Effective Date01/01/2026

Next Review DateN/A

Key ActionVerify member benefits and any prior authorization requirements for referenced CDT codes (e.g., D4230, D4231, D4268, D4274) before submitting services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 quadrantslimit per date of service

5 mmminimum pocket depth

12 monthscharting/rads dated

D4230, D4231, D4268, D4274example CDT codes

Coverage Criteria

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Medical necessity criteria

Covered when ALL of the following are met for the indicated procedures:

General indication: Periodontal surgical procedures are indicated when periodontal health cannot be achieved or maintained non-surgically and to eliminate pockets, recontour alveolar bone, or to expose or lengthen the clinical crown.

Documentation: Labeled and dated 6‑point periodontal pocket depth charting (within 12 months) and current diagnostic quality dated pretreatment radiographs (within 12 months) demonstrating horizontal and/or vertical osseous defects.

Procedure-specific: Distal/Mesial Wedge: For mesial/distal wedge: active periodontal disease with moderate to deep probing depths (greater than 5 mm) on a surface adjacent to an edentulous/terminal tooth area, and failure of non-surgical attempts or need for increased access to the root surface.>5 mm pocket depth

Timing after initial therapy: Completion of initial periodontal therapy (e.g., scaling and root planing) with a minimum of four weeks healing prior to surgical treatment (mesial/distal wedge).>=4 weeks after initial therapy

Tooth eligibility: Limited to natural teeth only; only teeth with favorable periodontal outcomes will be considered for benefit.

Indications in otherwise healthy areas: Indicated to remove enlarged gingival tissue and supporting bone to provide an anatomically correct gingival relationship, to allow proper contour of a restoration, or to manage a fractured tooth that extends subgingivally in an otherwise periodontally healthy area.

Limits: Procedures limited to two quadrants per date of service and limited to pocket depths of 5 mm or greater.

Exclusions: Procedures performed solely for cosmetic/aesthetic purposes are not indicated and therefore not covered. Also excluded are procedures for patients with uncontrolled underlying medical conditions, second-stage implant surgery, membrane removal, or retreatment of a failing soft tissue graft, and procedures in areas where treatment of cracked tooth, fractured root, or external root resorption can be managed noninvasively. These exclusions apply to the miscellaneous periodontal surgical procedures described in this policy.

Coverage clarifications: Procedures that are performed primarily for cosmetic purposes are not benefited; benefit determinations may also be group contract dependent. Surgical revision procedures or other repeat surgical services submitted within the plan’s frequency limitations of the initial surgical procedure may be disallowed or denied. Mesial/distal wedge and similar procedures are not indicated for patients who have been non-compliant with prior periodontal therapies and are not appropriate when performed solely for cosmetic reasons. Additionally, procedures in areas with teeth that have proximal contact are not indicated, and certain procedures are considered inclusive with other surgical procedures performed in the same anatomical area on the same date of service.

Coding

CDT codes (informational)CDT

D4230	Anatomical Crown Exposure four or more contiguous teeth
D4231	Anatomical Crown Exposure one to three contiguous teeth
D4268	Surgical Revision Procedure per tooth
D4274	Mesial/Distal Wedge Procedure single tooth

Diagnosis codesICD-10

ICD-10-CM

See the current CDT code book for diagnoses for dental diseases and conditions

inv-06: Periodontal pocket depth — minimum pocket depth requirement.

Minimum pocket depth requirementPeriodontal pocket depth recordings must be 5 mm or greater

Recording timingLabeled and dated 6‑point periodontal pocket depth charting must be available within 12 months of the submitted procedure

Tooth eligibilityLimited to natural teeth only; only teeth with favorable periodontal outcomes will be considered for benefit

Procedure limit per date of serviceProcedures limited to two quadrants per date of service (exceptions case-by-case)

Documentation linkageFor surgical revision: post-treatment charting; for mesial/distal wedge: pretreatment charting

Provider Actions and Requirements

Prior Authorization

Procedure codes — check member benefits

Verify member benefits and any prior authorization requirements for the CDT codes referenced by this policy before scheduling or billing.

Referenced CDT codes include D4230, D4231, D4268, D4274.

Step Therapy

Step therapy

No step therapy requirements are specified for these miscellaneous periodontal surgical procedures.

Documentation Required

Required clinical documentation

Submit labeled and dated 6‑point periodontal pocket depth charting and current diagnostic-quality pretreatment radiographs dated within 12 months as part of the clinical record.

For surgical revision: post-treatment labeled and dated 6-point periodontal pocket depth charting (within 12 months).
For mesial/distal wedge: pretreatment labeled and dated 6-point periodontal pocket depth charting (within 12 months).
Current diagnostic-quality, dated pretreatment radiographs (within 12 months) demonstrating horizontal and/or vertical osseous defects.

Documentation Required

Initial therapy and timing

Document completion of initial periodontal therapy and allow the minimum healing interval before performing certain surgical procedures.

For mesial/distal wedge: documentation that initial periodontal therapy (e.g., scaling and root planing) was completed and at least four weeks healing elapsed prior to surgery.

Denial Risk

Concomitant non-covered service

Services provided in conjunction with or in preparation for a non-covered or denied service will also be considered not covered or denied.

Billing Rule

Frequency and provider restrictions

Do not submit surgical revision or mesial/distal wedge procedures within the plan frequency limitations of the initial surgical procedure; such submissions will be disallowed or denied depending on provider.

When submitted within the plan frequency limitations by the same dentist/dental office the procedure is DISALLOWED.
When submitted within the plan frequency limitations by a different dentist/dental office the procedure is DENIED.
Periodontal surgical procedures are limited to two quadrants per date of service and limited to natural teeth only.

Background

Miscellaneous periodontal surgical procedures are performed when periodontal health cannot be achieved or maintained by non-surgical means. Indications include eliminating periodontal pockets, recontouring alveolar bone, exposing or lengthening the clinical crown, or refining results of a prior surgical procedure. The mesial/distal wedge is specifically used adjacent to an edentulous or terminal tooth area to remove tissue, provide access for root debridement, and reduce moderate to deep probing depths (typically > 5 mm). Surgical revision procedures are intended to modify irregular hard and/or soft tissue contours to improve periodontal anatomy or restorative access.

Definitions

inv-14: Mesial/Distal Wedge Procedure — definition and brief description of when performed and purpose.

DefinitionProcedure performed for a single tooth in an edentulous area adjacent to a tooth to remove tissue, gain access for debridement, aid cleaning of the mesial or distal area, and reduce pocket depths.

IndicationUsed when active periodontal disease with moderate to deep probing depths (>5 mm) exists on a surface adjacent to an edentulous/terminal tooth area

PrerequisiteCompletion of initial periodontal therapy (e.g., scaling and root planing) with a minimum of four weeks healing prior to surgery

inv-15: Surgical Revision Procedure — definition describing refinement of previously performed surgical procedures.

DefinitionProcedure used to refine results of a previously performed surgical procedure by modifying irregular hard and/or soft tissue contours.

PurposePerformed to modify irregular contour results of prior surgery to improve anatomy and periodontal outcomes

Documentation requirementPost-treatment labeled and dated 6‑point periodontal pocket depth charting (within 12 months) is required for surgical revision submissions