CurrentBlue Cross Blue Shield - NevadaPolicy 04-901

Periodontal Maintenance Guideline

Guideline defining periodontal maintenance as a nonsurgical, lifelong therapeutic phase following definitive periodontal therapy, outlining clinical indications, required history/documentation, and applicable CDT procedure codes. It is intended for use in utilization review and provider guidance and may be adopted variably by plans/lines of business.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyPeriodontal Maintenance Guideline

Policy CodePolicy 04-901

Change TypeAnnual reviews

Effective DateJan 1, 2022

Next Review Date

Key ActionProviders must document prior history of definitive periodontal therapy including dates and specific treatments rendered to support periodontal maintenance.

SourceLink

POLICY UPDATE CHANGES

Annual reviews and revisions recorded with dates including 11/10/2020, 12/05/2020 and 10/30/2021.

5Key clinical criteria listed

5CDT codes cited

Policy Overview

Background: Periodontal maintenance is defined as a nonsurgical, therapeutic, lifelong phase following definitive periodontal therapy intended to remove etiologic factors (plaque, biofilm, calculus) and to monitor periodontal disease. It is considered therapeutic rather than prophylactic and constitutes continuing treatment for patients with a diagnosis of periodontal disease.

Scope summary: This guideline defines periodontal maintenance as a nonsurgical, lifelong therapeutic phase following definitive periodontal therapy, outlines clinical indications, required history/documentation, and applicable CDT procedure codes. It is intended for use in utilization review and provider guidance and aligns with the American Academy of Periodontology position papers and peer-reviewed literature referenced in the guideline.

Provider Documentation & Authorization Requirements

Documentation Required

Document prior definitive periodontal therapy

Providers must document prior history of definitive periodontal therapy including dates and specific treatments rendered to support periodontal maintenance.

Document dates of definitive periodontal therapy
List specific treatments rendered (e.g., scaling and root planing, surgical therapy, etc.)

Documentation Required

Continuous care interval

Maintain record that periodontal maintenance represents continuous care not exceeding 12 months between maintenance visits.

Maintenance intervals should not exceed 12 months between visits
Relevant code: D4910 (Periodontal maintenance)

Prior Authorization

Letter of medical necessity for LACA

A letter of medical necessity is required for the use of locally administered chemotherapeutic agents (LACA).

Affected code: D4381

Relevant Procedure & Diagnosis Codes

Relevant CDT procedure codes (informational list)CPT

D4341	Periodontal scaling and root planing – four or more teeth per quadrant
D4342	Periodontal scaling and root planing – one to three teeth per quadrant (listed as "Less than three teeth per quadrant")
D4381	Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
D4910	Periodontal maintenance
D4999	Unspecified periodontal procedure, by report

ICD-10 CM DiagnosesICD-10

See CDT code book

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

Definitions & Rationale

Term: Periodontal maintenance — A nonsurgical, therapeutic procedure following definitive periodontal therapy to remove etiologic factors and monitor periodontal conditions for the life of the dentition or any implant placement.

Term: Locally administered chemotherapeutic agents (LACA) — Localized delivery of antimicrobial agents into diseased crevicular tissue (see D4381); use of LACA requires a letter of medical necessity per the guideline.

Evidence summary: Key references include multiple peer-reviewed studies and American Academy of Periodontology (AAP) position papers supporting maintenance therapy. The brief cites peer-reviewed literature and AAP position papers as primary supporting evidence (example: J Periodontol 2003;74:1395-1401).

Key Evidence

Key references and endorsements: The guideline cites multiple peer-reviewed studies on maintenance and nonsurgical periodontal therapy (for example, J Perio 1982;53:420-424; J Clin Perio 1981; and J Clin Perio 1984) and specifically references the American Academy of Periodontology position paper on periodontal maintenance (J Periodontol 2003;74:1395-1401). The document also lists relevant CDT codes associated with periodontal maintenance and adjunctive localized antimicrobial delivery (e.g., D4910, D4381) for informational purposes.

Policy Revision History

11/10/2020revision

Annual reviews and revisions recorded with dates including 11/10/2020, 12/05/2020 and 10/30/2021.

12/05/2020revision

Annual reviews and revisions recorded with dates including 11/10/2020, 12/05/2020 and 10/30/2021.

10/30/2021annual_reviewLatest

Annual reviews and revisions recorded with dates including 11/10/2020, 12/05/2020 and 10/30/2021. Annual Review by Committee.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyPeriodontal Maintenance Guideline

Policy CodePolicy 04-901

Change TypeAnnual reviews

Effective DateJan 1, 2022

Next Review Date

Key ActionProviders must document prior history of definitive periodontal therapy including dates and specific treatments rendered to support periodontal maintenance.

SourceLink

On This Page

OpenPayer

Periodontal Maintenance Guideline

Policy Overview

Clinical Indications / Criteria

Provider Documentation & Authorization Requirements

Relevant Procedure & Diagnosis Codes

Definitions & Rationale

Key Evidence

Policy Revision History