CurrentBlue Cross Blue Shield - MainePolicy 01 -101

Prophylaxis (2024 Policy) PDF. Opens in a new window

Defines clinical indications, risk assessment factors, and coding guidance for dental prophylaxis (preventive cleaning), full mouth debridement, oral hygiene instructions, and related periodontal procedures for children and adults as used by the plan for medical/dental necessity review.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyProphylaxis (2024 Policy) PDF. Opens in a new window

Policy CodePolicy 01 -101

Change TypeRevised

Effective DateJan 1, 2024

Next Review Date

Key ActionProviders must document presence of plaque/stain/calculus or other listed indications and the relevant risk assessment elements to support the need for prophylaxis.

SourceLink

POLICY UPDATE CHANGES

Policy status marked Revised with publish date 01/01/2024 and last review 08/23/2023.

8Core Indications Listed

8Risk Assessment Elements Listed

7CDT Codes Provided

Coverage Summary

This policy (Policy Number 01 -101, effective 01/01/2024) defines coverage guidance for dental prophylaxis (preventive cleaning), full mouth debridement, and oral hygiene instructions for both children and adults. Coverage is mixed/conditional and determined according to contractual requirements and the plan’s medical/dental necessity review; whether a service is covered for a particular member depends on the member’s contract and whether the service meets the plan’s criteria and generally accepted standards of dental practice.

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Medical Necessity Criteria

Indications for Dental Prophylaxis (Medically/Dentally Necessary)

Covered when ALL of the following clinical indications or risk factors support the need for prophylaxis:

At least one clinical indication

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

Risk assessment elements to consider

Medical and dental history including any medications
Age
Compliance with treatment recommendations
Previous and current evidence of caries
Previous and current periodontal health evaluation
Family or patient history of periodontal disease
Oral hygiene compliance
Presence of plaque
Presence of gingivitis - bleeding (spontaneous or upon probing)
Presence of calculus
Presence of external tooth staining (e.g., coffee or tea staining)
Local factors influencing the build-up and retention of plaque

Full Mouth Debridement

Full mouth debridement is appropriate when plaque and calculus interfere with the ability to perform a comprehensive oral evaluation:

ALL of the following

Plaque and calculus that interferes with the ability of the dentist to perform a comprehensive oral evaluation
Full mouth debridement may be performed as a preliminary treatment to enable a comprehensive oral evaluation and diagnosis on a subsequent visit

Oral Hygiene Instructions

Oral hygiene instruction may be provided during prophylaxis when necessary:

Oral hygiene instructions provided to the patient or caregiver as needed during a dental prophylaxis

Provider Actions & Billing Guidance

Documentation Required

Document clinical indications and risk assessment

Providers must document the presence of plaque, stain, or calculus or other listed clinical indications and the relevant risk assessment elements (medical/dental history, periodontal status, oral hygiene compliance, etc.) to support the need for prophylaxis.

D1110
D1120
D4355
D4910

Billing Rule

Use CDT codes for claim submission (informational)

Report the applicable CDT code for the service performed; inclusion in this list is informational and does not guarantee coverage—verify member contract benefits at the time of service.

D1110
D1120
D1330
D4341
D4342
D4346
D4355
D4910
Inclusion is informational and not a guarantee of coverage

Documentation Required

Full mouth debridement justification

Document that plaque and/or calculus obstructs the ability to perform a comprehensive oral evaluation to justify use of D4355 as a preliminary treatment prior to a comprehensive evaluation.

D4355

Coding

CDT codes (informational list)mixed

D1110	Prophylaxis - adult
D1120	Prophylaxis - child
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 Diagnoses (informational)ICD-10

No codes listed

Background

Purpose: This policy provides guidance on dental prophylaxis that aligns with generally accepted standards of dental practice and contractual requirements. It clarifies when prophylaxis and full mouth debridement are considered appropriate and identifies risk assessment factors used to guide determinations of dental necessity.

Dental prophylaxis: A routine preventive procedure to remove supragingival plaque, stain, and calculus from tooth surfaces using scaling (above the gingival sulcus), ultrasonic, or hand instruments; includes observation of hard and soft tissues.

Full mouth debridement: Preliminary treatment to remove plaque and calculus that interfere with the ability to perform a comprehensive oral evaluation; followed by evaluation on a subsequent visit.

Generally accepted standards of dental practice: Standards based on credible scientific evidence, specialty society recommendations, the views of recognized practicing dentists, and other relevant credible sources.