CurrentBlue Cross Blue Shield - MainePolicy 04-301

Scaling and Root Planing

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Defines clinical indications, documentation, and coding guidance for periodontal scaling and root planing and related procedures for Blue Cross Blue Shield - Maine members; applies to providers performing nonsurgical periodontal therapy.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyScaling and Root Planing

Policy CodePolicy 04-301

Change TypeRevised — no material clinical changes

Effective DateJan 1, 2025

Last ReviewAug 29, 2024

Next Review DateJan 1, 2025

Key ActionWhen requesting payment for scaling and root planing, include pretreatment radiographs and 6-point periodontal charting (within 12 months); additional documentation may be requested for treatment of more than two quadrants.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 mmpocket depth threshold

1.5 mmbone loss threshold

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CurrentBlue Cross Blue Shield - MainePolicy 04-301

Scaling and Root Planing

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Sign up for Blue Cross Blue Shield - Maine Policy 04-301 alerts

Get alerted when Policy 04-301 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyScaling and Root Planing

Policy CodePolicy 04-301

Change TypeRevised — no material clinical changes

Effective DateJan 1, 2025

Last ReviewAug 29, 2024

Next Review DateJan 1, 2025

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 mmpocket depth threshold

1.5 mmbone loss threshold

Coverage Criteria for Scaling and Root Planing

Initial scaling and root planing

Covered when ALL of the following are met

Primary coverage criteria: 1) Teeth in the treatment area demonstrate periodontal pocket depths >= 4 mm; 2) There is bleeding on probing/clinically evident inflammation; 3) Radiographic evidence of alveolar bone loss (bone level > 1.5 mm apical to the cementoenamel junction [CEJ]); 4) Diagnosis consistent with qualifying periodontal diagnoses (chronic periodontitis, localized or generalized aggressive periodontitis, periodontitis as a manifestation of systemic disease, or necrotizing periodontal diseases) and in accordance with current AAP staging/grading; 5) Local anesthesia administered by intramucosal injection for the procedure (topical or subgingival anesthetic preparations do not qualify); 6) Provision of required, dated pretreatment radiographs and 6-point periodontal charting within the prior 12 months; 7) Post-initial therapy evaluations and treatment planning recommendations documented as integral components when applicable.Pocket depth >= 4 mm; bone loss > 1.5 mm apical to CEJ; radiographs/periodontal charting within 12 months

Some numbered items in source are archived and omitted; criteria reflect source clinical indications and adjunctive documentation.

Quadrant limits and documentation

Additional operational criteria and documentation

Quadrant and time documentation: If more than two quadrants are treated in one appointment, additional clinical and/or administrative documentation may be requested; documentation of the duration of treatment times for periodontal scaling and root planing may be required for individual case review.Partial quadrant = at least one tooth with >= 4 mm; Full quadrant = at least four teeth with >= 4 mm

Quadrant definitions and documentation requirements are per policy criteria.

Scaling in the presence of gingival inflammation is a distinct procedure from scaling and root planing (SRP). The policy defines scaling in the presence of generalized, moderate, or severe gingival inflammation as removal of plaque, calculus, and stain from supra- and sub-gingival tooth surfaces when there is clinically evident inflammation but no radiographic bone loss. This condition corresponds to CDT code D4346 and is not an indication for SRP, which requires objective evidence of pocketing and alveolar bone loss.

By contrast, SRP (CDT codes D4341/D4342) is indicated only when periodontal disease has produced attachment loss and radiographic bone loss; simple scaling for gingival inflammation without bone loss should be reported as D4346 rather than SRP.

Procedures will not be supported as scaling and root planing unless there is documented objective evidence that meets the policy thresholds. Specifically, the teeth to be treated must show periodontal pocket depths of at least 4 mm with bleeding on probing and demonstrable radiographic alveolar bone loss — defined as bone level > 1.5 mm apical to the CEJ. Absent documentation of these findings, periodontal therapy should not be billed or reimbursed as SRP.

Providers should ensure pretreatment periodontal charting and radiographs that demonstrate the required pocket depths and bone loss are included with the request; failure to document pocket depths ≥ 4 mm and radiographic bone loss > 1.5 mm apical to the CEJ may result in denial.

Coding, Thresholds, and Documentation Recency

CDT codes referencedCDT

D1110	Prophylaxis - adult
D1120	Prophylaxis - child
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 periodontal evaluation and diagnosis on a subsequent visit

inv-06: Pocket depth threshold — >= 4 mm

Pocket depth threshold>= 4 mm pocket depth required to qualify for scaling and root planing

Quadrant definition (partial)At least one tooth in the quadrant with pocket depth >= 4 mm

Quadrant definition (full)At least four teeth in the quadrant with pocket depths >= 4 mm

inv-07: Bone loss threshold — > 1.5 mm apical to CEJ

Bone loss thresholdRadiographic bone loss defined as bone level > 1.5 mm apical to the CEJ

Acceptable bone loss typesVertical or horizontal alveolar crest bone loss qualifies

Documentation and Provider Requirements

Prior Authorization

Documentation required for coverage requests

When requesting payment for scaling and root planing (D4341, D4342, D4346, D4355), include pretreatment radiographs and periodontal charting; additional clinical and/or administrative documentation may be requested when more than two quadrants are treated in one appointment.

Include current (within 12 months), dated pretreatment full mouth radiographic images and/or panoramic with bitewings.
Include current (within 12 months), dated 6‑point periodontal charting.
Be prepared to supply additional documentation when >2 quadrants are treated during one appointment.

Step Therapy

Post-therapy evaluation must be documented

Document post-initial therapy evaluations and treatment planning recommendations as they are considered integral components of scaling and root planing and should be included in the patient record.

Background

Scaling and root planing (SRP) is a nonsurgical therapeutic procedure that instruments the crown and root surfaces to remove plaque and calculus and to treat periodontal disease by addressing epithelial attachment migration that has created periodontal pockets. SRP is typically performed with hand or ultrasonic instruments and may require local anesthesia administered by intramucosal injection as part of the procedure.

SRP is indicated when there is clinical evidence of periodontitis — namely periodontal pocketing of at least 4 mm, bleeding on probing/clinically evident inflammation, and radiographic alveolar bone loss (bone level > 1.5 mm apical to the CEJ). Full mouth debridement (D4355) is a separate preliminary procedure used only when heavy deposits prevent an adequate periodontal evaluation and diagnosis at the same visit.

Definitions

inv-14: Scaling in presence of gingival inflammation — definition (D4346) and distinction from SRP

CDT codeD4346 — Scaling in presence of generalized moderate or severe gingival inflammation (full mouth after oral exam)

DefinitionRemoval of plaque, calculus, and stain from supra- and sub-gingival tooth surfaces when there is inflammation but no bone loss

Distinction from SRPD4346 is indicated for generalized gingival inflammation without bone loss and is a separate indication from periodontal scaling and root planing (which requires >=4 mm pockets and radiographic bone loss)

inv-15: Full mouth debridement (D4355) — preliminary removal enabling definitive diagnosis

CDT codeD4355 — Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit

Definition