CurrentBlue Cross Blue Shield - NevadaPolicy 04-207

Dental Clinical Policy

Defines clinical indications, documentation, limitations, and coding guidance for coverage determination of gingival flap procedures (including root planing) and apically positioned flaps for periodontal disease under the dental clinical policy.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyDental Clinical Policy

Policy CodePolicy 04-207

Change TypeRevised (last review 10/30/2021)

Effective DateJan 1, 2022

Next Review Date

Key ActionSubmit current (within 12 months) 6-point periodontal charting showing pocket depths (minimum 5mm) after completion of non-surgical therapy or maintenance (D4341/D4342 or D4910).

SourceLink

POLICY UPDATE CHANGES

Policy status shows 'Revised' with last review date 10/30/2021 (annual review).

3Primary CDT procedure codes listed

2Quadrant limit per date of service

5mmMinimum pocket depth for coverage

Coverage Summary

Key thresholds and quick facts

Minimum pocket depth for coverage>= 5 mm (6‑point periodontal charting)

Periodontal charting recency requirementCurrent within 12 months (dated 6‑point periodontal charting after completion of non‑surgical therapy or maintenance)

Quadrant limit per date of service2 quadrants per date of service (exceptions case‑by‑case)

Primary CDT procedure codes listedD4240, D4241, D4245 (Gingival flap procedures and apically positioned flap)

Medically/Dentally Necessary Criteria

Covered when ALL of the following are met:

ALL of the following

Treatment is for diseased gingiva after nonsurgical methods, such as root planing and scaling, have been unsuccessful in removal of subgingival plaque and calculus.
Periodontal charting, after completion of non-surgical periodontal therapy (D4341/D4342) or periodontal maintenance (D4910) is required.
Current (within 12 months) dated periodontal charting (6 point periodontal charting) indicating pocket depth recordings of a minimum of 5mm.pocket depth >= 5 mm
Current pre-treatment radiographs showing periapical area and undistorted image of the alveolar crest.
Procedure indicated in the presence of supra-bony pocket depths where there is a need for increased access to root surfaces.
Chart notes may be requested to demonstrate a soft tissue flap was reflected/resected or planned to allow debridement of the root surface and removal of granulation tissue.
Osseous recontouring is not accomplished with this procedure.
Procedure is performed on natural teeth only (not around implants).

Coverage Limitations and Non-Covered Indications

Not covered when ANY of the following apply:

ANY of the following

Procedure performed for infra-bony pockets.
Treatment of pockets extending below the mucogingival junction.
Procedure performed for presence of minimal amounts of attached keratinized tissue.
Procedure performed around implants.
Use of lasers billed as a separate/additional benefit.
For benefit determination, lasers are considered an adjunct and not eligible for additional/separate benefit.

Benefit limits

Benefits will be limited to two quadrants per date of service.

Provider Actions

Documentation Required

Periodontal charting required

Submit current (within 12 months) 6-point periodontal charting showing pocket depths (minimum 5mm) after completion of nonsurgical therapy or maintenance.

D4341
D4342
D4910

Documentation Required

Pre-treatment radiographs required

Provide current pre-treatment radiographs that show the periapical area and an undistorted image of the alveolar crest.

Documentation Required

Chart notes may be requested

Be prepared to supply chart notes documenting that a soft tissue flap was reflected/resected or planned to allow root debridement and granulation tissue removal; confirm no osseous recontouring was performed.

Billing Rule

Quadrant limit per date of service

Benefits are limited to two quadrants per date of service; exceptions may be granted case-by-case.

limit = 2 quadrants

Denial Risk

Laser adjunct not separately billable

Claims billing laser use as an additional/separate benefit may be denied because laser use is considered an adjunct and not eligible for separate benefit.

Background and Evidence

This policy governs review of gingival flap and apically positioned flap procedures to ensure services meet generally accepted standards of dental care and contractual requirements. The plan reviews these procedures to confirm they meet accepted standards of care and contract terms. The conclusion that a service is medically or dentally necessary does not constitute a warranty that the service is a covered benefit payable by the dental plan; member contract benefits prevail.

References: ADA CDT; AAP guidelines and position papers; Proceedings of the World Workshop in Clinical Periodontics; ADA statement on lasers.

Definitions

Policy metadata

Revision History

11/04/2020annual_review

Annual review (Revision History entry: Revised on 11/04/2020).

12/04/2020annual_review

Annual review (Revision History entry: Revised on 12/04/2020).

10/30/2021annual_reviewLatest

Annual review (Revision History entry: Revised on 10/30/2021). Policy status shows "Revised" with last review date 10/30/2021 (annual review).

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyDental Clinical Policy

Policy CodePolicy 04-207

Change TypeRevised (last review 10/30/2021)

Effective DateJan 1, 2022

Next Review Date

Key ActionSubmit current (within 12 months) 6-point periodontal charting showing pocket depths (minimum 5mm) after completion of non-surgical therapy or maintenance (D4341/D4342 or D4910).

SourceLink

On This Page

OpenPayer

Dental Clinical Policy

Coverage Summary

Medically/Dentally Necessary Criteria

Coverage Limitations and Non-Covered Indications

Coding

Provider Actions

Background and Evidence

Revision History

D4240	Gingival Flap Procedure including root planing - four or more teeth
D4241	Gingival Flap Procedure including root planing - one to three teeth
D4245	Apical Positioned Flap