CurrentBlue Cross Blue Shield - MainePolicy 04-208

Periodontic Surgical Procedures, miscellaneous (2022 Policy) PDF. Opens in a new window

Defines clinical review criteria, limitations, and billing guidance for miscellaneous periodontal surgical procedures (periodontics) performed under the plan; includes documentation, clinical indications/contraindications, frequency and quadrant limits, and example CDT codes for informational purposes. Coverage is contract-dependent.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyPeriodontic Surgical Procedures, miscellaneous (2022 Policy) PDF. Opens in a new window

Policy CodePolicy 04-208

Change TypeClarified (annual review)

Effective DateJan 1, 2022

Next Review Date

Key ActionProvider must submit labeled and dated 6-point periodontal pocket depth charting (within 12 months) and dated, labeled diagnostic radiographic images demonstrating osseous defects; include pre- and post-non-surgical therapy documentation.

SourceLink

POLICY UPDATE CHANGES

Policy status shows 'Revised' with last review 10/30/2021 and publish date 01/01/2022.

2Quadrants allowed per date of service

1Procedures allowed per quadrant

36Typical frequency (months)

>=5mmMinimum pocket depth for coverage

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Summary

This policy addresses miscellaneous periodontal surgical procedures and defines clinical review criteria, documentation requirements, limitations, and billing guidance for those procedures. Benefits and final determinations are group contract dependent and the plan requires that requested services meet generally accepted standards of dental care and the member's contract terms (including any requirement that services be provided at the lowest cost consistent with proper care).

Coverage is limited by clinical and administrative rules: cosmetic or primarily aesthetic procedures are not covered, benefits are limited to natural teeth only, and services may be disallowed or denied when documentation is inadequate or when procedures duplicate prior services within plan frequency limitations. Documentation-dependent requirements include labeled and dated 6-point periodontal charting within 12 months, dated labeled diagnostic radiographs demonstrating osseous defects, and documentation of pre- and post-non-surgical periodontal therapy.

Frequency and scope limits summarized: benefits are generally limited to two quadrants per date of service, typically one periodontal surgical procedure per quadrant, and generally limited to once every 36 months; minimum pocket depth for coverage is >= 5 mm. Exceptions to quadrant or frequency limits may be considered on a case-by-case basis and additional information may be requested.

Summary of Limits and Thresholds

Quadrants allowed per date of service2

Procedures allowed per quadrant (generally)1

Typical frequency limitation36 months

Minimum pocket depth for coverage>= 5 mm

Documentation recency for chartingwithin 12 months

Minimum healing time after initial therapy>= 4 weeks

Medical Necessity & Coverage Criteria

General Documentation and Eligibility Criteria

Covered when ALL of the following are met:

Periodontal charting is submitted

Charting must be labeled and dated within 12 months of submitted procedure and include 6-point periodontal pocket depth charting; include pre- and post non-surgical periodontal therapy.

Diagnostic quality radiographic images are submitted

Dated, labeled images demonstrating horizontal and/or vertical osseous defects.

Completion of initial periodontal therapy

Initial therapy (e.g., scaling and root planing) must be completed with a minimum of four weeks allowed prior to any surgical treatment to allow healing and proper assessment.

Periodontal pocket depth threshold>= 5 mm

Coding

Informational CDT codes (included but not definitive for coverage)mixed

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 coding referenceICD-10

See current CDT/ICD code book

IDC-10 CM Diagnoses for Dental Diseases and Conditions: see current CDT code book for details

Provider Actions & Billing Guidance

Documentation Required

Submit periodontal charting and radiographs

Provider must submit labeled and dated 6-point periodontal pocket depth charting (within 12 months) and dated, labeled diagnostic radiographic images demonstrating osseous defects. Include documentation of pre- and post-non-surgical periodontal therapy.

6-point periodontal charting labeled and dated within 12 months
Dated, labeled diagnostic radiographs demonstrating horizontal and/or vertical osseous defects
Documentation of pre- and post-non-surgical periodontal therapy

Prior Authorization

Plan/contract dependent benefits and case-by-case exceptions

Verify the member's group contract for specific coverage, limits, and whether review/approval is required. Exceptions to quadrant or frequency limits may be considered on a case-by-case basis and additional information may be requested.

Background & Definitions

This policy addresses miscellaneous periodontal surgical procedures and specifies the clinical review criteria used to determine medical/dental necessity. Final coverage decisions remain contract dependent and require that services meet generally accepted standards of dental practice.

Clinical review criteria include submission of labeled, dated 6-point periodontal pocket depth charting (within 12 months), diagnostic quality radiographs demonstrating horizontal and/or vertical osseous defects, completion of initial periodontal therapy with a minimum healing interval of 4 weeks prior to surgery, a periodontal pocket depth threshold of >= 5 mm, limitation to natural teeth, and limits on quadrants and frequency (generally 2 quadrants per date of service, one procedure per quadrant, and generally every 36 months).

Generally accepted standards of dental practice — Standards that are based on credible scientific evidence published in peer-reviewed dental literature generally recognized by the practicing dental community; specialty society recommendations/criteria; the views of recognized dentists practicing in the relevant clinical area; and any other relevant factors from credible sources.

Revision History

09/12/2018Revision

Initial version recorded in revision history (09/12/18)

11/10/2020Annual Review

Annual review entry recorded in revision history (11/10/2020)

12/04/2020Annual Review

Annual review entry recorded in revision history (12/04/2020)

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyPeriodontic Surgical Procedures, miscellaneous (2022 Policy) PDF. Opens in a new window

Policy CodePolicy 04-208

Change TypeClarified (annual review)

Effective DateJan 1, 2022

Next Review Date

SourceLink

On This Page

Benefits limited to periodontal pocket depth recordings of 5mm or greater.

Teeth type

Limited to natural teeth only.

Quadrant and frequency limits<= 2 quadrants; generally once every 36 months

Benefits limited to two quadrants per date of service; generally limited to one periodontal surgical procedure per quadrant and generally limited to once every 36 months; exceptions considered case-by-case.

Coverage is group contract dependent

Final benefits determination depends on member's contract.

Indications for Anatomical Crown Exposure / Crown-Lengthening

Procedure is indicated when ANY of the following are met:

To remove enlarged gingival tissue and supporting bone to provide an anatomically correct gingival relationship in an otherwise periodontally healthy area.

To allow proper contour of a restoration in an otherwise periodontally healthy area.

To allow management of a fractured tooth in which the fracture extends subgingivally in an otherwise periodontally healthy area.

Indications for Surgical Revision / Refinement

Procedure is indicated when ANY of the following are met:

To refine the results of a previously provided surgical procedure.

To modify irregular contours of hard or soft tissue.

Indications for Procedures Adjacent to Edentulous/Terminal Tooth Areas

Procedure is indicated when ALL of the following are met:

Presence of active periodontal disease and moderate to deep probing depths on a surface adjacent to an edentulous/terminal tooth area> 5 mm

On a surface adjacent to an edentulous/terminal tooth area.

Need for increased access to root surface when previous non-surgical attempts have been unsuccessful on a surface adjacent to an edentulous/terminal tooth area

Exclusions / Not Indicated

The following are NOT indications and are excluded or denied:

Procedures performed solely for cosmetic/aesthetic purposes

Primarily cosmetic procedures are not covered.

Patients with an uncontrolled underlying medical condition

Procedures for patients non-compliant with previous periodontal therapies

Procedures in areas with teeth that have proximal contact (for certain adjacent edentulous-area procedures)

Such areas are listed as not indicated for the edentulous/terminal adjacent procedures.

Second stage implant surgery, membrane removal, or redoing a failing soft tissue graft

Listed as not indicated for the 'refinement' procedure category.

Diagnosis of cracked tooth, fractured root or external root resorption on a surface adjacent to an edentulous/terminal tooth area when this cannot be accomplished by non-invasive methods

Listed as not indicated for the edentulous/terminal adjacent procedures.

Procedure Billing Relationships / Inclusion Rules

Operational determinations regarding billing and prior procedures:

When a refinement/modification procedure is billed within plan frequency limitations by the same dentist/dental office the procedure is DISALLOWED

When billed within the plan frequency limitations of the initial surgical procedure by the same dentist/dental office this procedure is DISALLOWED.

When a refinement/modification procedure is billed within plan frequency limitations by a different dentist/dental office the procedure is DENIED

When billed within the plan frequency limitations of the initial surgical procedure by a different dentist/dental office this procedure is DENIED.

When a procedure is performed in conjunction with or in preparation for a non-covered or denied service all related services are also not covered or denied

Procedures performed with or for a non-covered service are also not covered or denied.

Some procedures are considered inclusive with other surgical procedures in the same anatomical area performed on the same date of service and are not separately covered

Those are considered inclusive and not separately covered.

Confirm allowed quadrants per date of service (benefits limited to two quadrants; exceptions case-by-case)

Confirm frequency limits per quadrant (generally once every 36 months) and whether review/approval is required

Billing Rule

Frequency and provider limits affect payment

Frequency and provider limits affect payment. When refinement/modification procedures are billed within the plan frequency limitations by the same dentist/dental office the procedure is DISALLOWED; when billed within the plan frequency limitations by a different dentist/dental office the procedure is DENIED. Procedures performed in conjunction with or in preparation for a non-covered or denied service are also not covered or denied.

Same office billing within frequency limits = DISALLOWED
Different office billing within frequency limits = DENIED
Procedures tied to non-covered or denied services are not covered/are denied

10/30/2021RevisedLatest

Revised (annual review) with last review 10/30/2021 and publish date 01/01/2022; non-material (annual review)