CurrentBlue Cross Blue Shield - MainePolicy 04-301

Scaling and Root Planing

Policy governing clinical review and documentation requirements for periodontal scaling and root planing (non‑surgical periodontal therapy) for Blue Cross Blue Shield - Maine members; affects providers seeking coverage/payment for these dental services.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyScaling and Root Planing

Policy CodePolicy 04-301

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review Date

Key ActionProvide current (within 12 months) pretreatment full mouth radiographs or panoramic with bitewings and current (within 12 months) 6‑point periodontal charting with submitted claims or prior authorization requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 mmpocket depth threshold

≥1.5 mmradiographic bone loss

D4341/D4342primary CDT codes

12 moradiograph/charting recency

Coverage Criteria for Scaling and Root Planing

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Medical necessity criteria for SRP

Covered when ALL of the following are met

Primary clinical criteria: Teeth to be treated must demonstrate at least 4 mm pocket depths with bleeding on probing and demonstrable radiographic evidence of bone loss (bone level > 1.5 mm apical to the cementoenamel junction); procedure is a non‑surgical therapeutic treatment for mild to severe periodontitis.pocket >=4 mm; bone loss >1.5 mm apical to CEJ

See definitions for radiographic threshold

Quadrant qualification: At least 1 tooth in the quadrant with pocket depth >= 4 mm for a partial quadrant, or at least 4 teeth in the quadrant with pocket depths >= 4 mm for a full quadrant.>=1 tooth (partial) or >=4 teeth (full) with pockets >=4 mm

Anesthesia requirement: Procedure requires administration of local anesthesia by intramucosal injection; topical or subgingival anesthetic preparations do not satisfy this requirement.local intramucosal anesthesia

Documentation requirement: Current (within 12 months), dated pretreatment full‑mouth radiographs or panoramic radiograph with bitewings and current (within 12 months) 6‑point periodontal charting must be provided; documentation of treatment time, clinical inflammation/bleeding, and post‑therapy evaluations may be requested; additional documentation may be requested when more than two quadrants are treated in one appointment.radiographs & charting within 12 months

Additional documentation may be requested for >2 quadrants treated in one appointment

Eligible diagnoses: Diagnoses that qualify for payment include chronic periodontitis, localized and generalized aggressive periodontitis, periodontitis as a manifestation of systemic disease, and necrotizing periodontal diseases; gingival diseases (plaque‑induced or non‑plaque induced) do not qualify for payment.

Scaling and debridement of implants is considered inclusive with D4341 and D4342 (not separately payable).

Coding and Clinical Thresholds

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

inv-06: Periodontal pocket depth — >= 4 mm

Minimum pocket depth>= 4 mm

Bleeding on probingRequired in teeth to be treated

Quadrant treatment thresholdsPartial quadrant: ≥1 tooth with >=4 mm; Full quadrant: ≥4 teeth with >=4 mm

Clinical intentPockets due to migration of epithelial attachment indicating periodontitis

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

Radiographic bone loss threshold> 1.5 mm apical to the CEJ

Anatomic referenceMeasured from cementoenamel junction (CEJ) to bone level

Types of loss consideredVertical or horizontal alveolar crest bone loss qualifies

Provider Responsibilities and Documentation Requirements

Prior Authorization

Prior authorization and coverage note

Coverage determinations for scaling and root planing require clinical documentation and are subject to the member's contract. Inclusion or exclusion of a code does not confer coverage; services determined not to meet member contract benefits may be denied.

Refer to the member's contract benefits to determine coverage at time of service.
Inclusion or exclusion of codes is informational only and not a guarantee of payment.

Documentation Required

Required diagnostic and adjunctive documentation

Require current, dated pretreatment diagnostic information to support review of scaling and root planing services.

Current (within 12 months) full‑mouth radiographic images and/or a panoramic radiograph with bitewings.
Current (within 12 months) pretreatment 6‑point periodontal charting (periodontal probing depths).

Documentation Required

Adjunctive documentation and post‑therapy evaluation

Documentation of treatment specifics and clinical findings may be requested for individual case review.

Record duration of treatment times for scaling and root planing when applicable.
Document clinical parameters supporting therapy: pocket depths (including ≥4 mm), clinically evident inflammation and/or bleeding.
Post‑initial therapy evaluations and treatment planning recommendations following completion of scaling and root planing are considered integral to the procedure and should be documented but are not billed separately.

Denial Risk

Coverage contingent on member contract

Inclusion of a code or documentation does not override contract exclusions or guarantee payment; coverage is contingent on member contract terms.

Services determined not to meet the member's contract benefits may be denied upon review.
Clinical necessity determinations do not equate to coverage determinations.

Background

Scaling and root planing is a non‑surgical therapeutic periodontal procedure performed to remove plaque, biofilm, adherent calculus, and diseased cementum from crown and root surfaces to treat periodontal pockets. The procedure is indicated when epithelial attachment loss has produced pockets of ≥ 4 mm and is technique sensitive; it commonly requires administration of local intramucosal anesthesia and is performed with hand or ultrasonic instrumentation.

Definitions

inv-13: Scaling and root planing (SRP)

DefinitionA non-surgical periodontal procedure involving instrumentation of crown and root surfaces to remove plaque, biofilm, adherent calculus and diseased cementum

PurposeTreat periodontal pockets of at least 4 mm caused by epithelial attachment migration

TechniquePerformed with hand and/or ultrasonic instrumentation, commonly under local intramucosal anesthesia

Tissue removedIncludes removal of cementum and dentin permeated by calculus, toxins, and microorganisms

inv-14: Radiographic bone loss — Bone level greater than 1.5 mm apical to the cementoenamel junction (CEJ).

Radiographic criterionBone level greater than 1.5 mm apical to the cementoenamel junction (CEJ)

Evidence requiredDemonstrable radiographic evidence of bone loss (vertical or horizontal) of the alveolar crest

Documentation timeframePretreatment radiographs must be current within 12 months