CurrentBlue Cross Blue Shield - NevadaPolicy 04-205

Osseous Surgery (Periodontal)

Policy governing clinical appropriateness and utilization review criteria for osseous periodontal surgery (including peri-implant osseous recontouring) for members covered by the plan; applies to providers requesting coverage for periodontal surgical services.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyOsseous Surgery (Periodontal)

Policy CodePolicy 04-205

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization when requesting osseous surgery codes and submit current 6‑point periodontal charting and diagnostic radiographs per documentation requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=5 mmminimum pocket depth required

within 12 monthscharting recency

2quadrant limit per date

1procedure limit (per tooth/quadrant)

D4260,D4261,D6101,D6102example CDT codes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Appropriate/Medically Necessary Osseous Surgery

Covered when ALL of the following are met

Prerequisite therapy: Completion of initial periodontal therapy (e.g., scaling and root planing) with a minimum 4-week healing and reassessment period4 weeks post-therapy

From criteria point 1

Pocket depth requirement: Post-initial therapy pocket depths >= 5 mm with spontaneous bleeding or bleeding on probing>= 5 mm

Criteria points 2 and 3; clinical indication requires >=5 mm with spontaneous bleeding or bleeding on probing

Documentation requirement: Current (within 12 months) dated 6‑point periodontal charting and clinical diagnostic radiographic images demonstrating horizontal and/or vertical osseous defects; if radiographs are non-diagnostic, submit a detailed narrative describing periodontal case type, percent bone loss, furcation involvement and vertical defectcharting within 12 months

Criteria points 3-5

Frequency and quantity limits: Benefits limited to two quadrants per date of service; limited to one osseous surgical procedure in a given period per single tooth or multiple teeth in the same quadrant (group contract dependent)2 quadrants per date of service; 1 procedure per period per tooth/quadrant

Criteria points 6 and 7

Scope of procedure inclusion: Associated periodontal surgical procedures (e.g., gingivectomy/gingivoplasty, anatomical crown exposure, gingival flap procedures, apically repositioned flap, clinical crown lengthening, surgical revision) are considered inclusive with osseous surgery

Criteria point 8

Determination that osseous surgery is medically/dentally necessary is based on clinical review against the policy criteria, but such a determination does not guarantee that the service will be a covered benefit under a member's plan. Coverage and payment depend on the member's specific contract terms and benefit limitations; the plan may deny or limit payment even when the procedure meets clinical necessity standards.

Services that fail to meet the policy's clinical criteria are not considered medically/dentally necessary and are subject to denial. Examples include cases without documented completion and reassessment of initial non‑surgical therapy (minimum four‑week healing), insufficient probing depths for surgical candidacy (i.e., pockets < 5 mm after initial therapy), or missing required documentation such as current (within 12 months) 6‑point periodontal charting and diagnostic radiographs demonstrating horizontal and/or vertical osseous defects. Additionally, services performed in conjunction with or preparatory to a non‑covered or denied service will also be non‑covered or denied.

Coding and Procedural Requirements

Included CDT codesCDT

D4260	Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant.
D4261	Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant.
D6101	Debridement and osseous recontouring of peri-implant defect or defects surrounding a single implant, surface cleaning of the exposed implant surfaces, including flap entry and closure.
D6102	Debridement and osseous recontouring of a peri-implant defect or defects surrounding a single implant, and includes surface cleaning of the exposed implant surfaces, including flap entry and closure.

Minimum probing depth for surgical consideration

Minimum probing depth>= 5 mm

Associated bleeding requirementSpontaneous bleeding or bleeding on probing must be demonstrated

Post-therapy measurementPocket depths must be documented post-initial (non-surgical) therapy

Periodontal charting recency

Required recency of periodontal chartingCurrent (within 12 months) dated 6‑point periodontal charting

Charting standard6‑point periodontal charting as described by AAP and ADA

Use for documentationCharting must indicate pocket depth recordings of a minimum of 5 mm

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required when requesting osseous surgery procedure codes. Submit supporting documentation at time of request, including current periodontal charting and diagnostic radiographs. Examples of procedure codes for which prior authorization/review is expected include, but are not limited to: osseous surgery codes and related periodontal surgical procedure codes.

Examples: osseous surgery and associated periodontal surgical procedure codes (e.g., osseous resective procedures, apically repositioned flap, clinical crown lengthening, surgical revision) — specific code sets vary by billing system and plan contract. Submit procedure codes on the authorization request.

Documentation Required

Non-surgical Therapy Prerequisite

Completion of initial non-surgical periodontal therapy (for example, scaling and root planing) and a documented reassessment are required prior to osseous surgery. Allow a minimum four-week healing period after non-surgical therapy before evaluating for surgery to assess the success or failure of non-surgical treatment.

Documented reassessment must demonstrate pocket depths ≥5 mm post‑therapy to support surgical indication.

Documentation Required

Required Documentation

Submit current (within 12 months), dated 6‑point periodontal charting and diagnostic radiographic images with any osseous surgery request. If radiographs do not clearly demonstrate osseous defects, include a detailed narrative describing periodontal case type, percentage of bone loss, measured furcation involvement, and description of any vertical defect. Benefits are subject to quadrant and frequency limits per group contract.

Required: dated 6‑point periodontal charting (within 12 months)
Required: diagnostic radiographic images showing horizontal and/or vertical osseous defects or a detailed clinical narrative when images are nondiagnostic
Limitations: benefits limited to two quadrants per date of service and to one osseous procedure per period per tooth/quadrant unless exception granted

Denial Risk

Related Non‑Covered Services

When a requested or performed service is non-covered or denied, any services performed in conjunction with or preparatory to that non-covered or denied service will also be non-covered or denied. Confirm coverage and authorization prior to performing related procedures.

Related non-covered services include preparatory or adjunctive periodontal procedures performed solely to enable a non-covered surgery
Verify group contract provisions and obtain prior authorization where required to avoid denials

Definitions

Osseous surgery — procedure definition

Core definitionSurgical procedure including elevation of a full‑thickness flap, debridement and osseous recontouring of defects around natural teeth or implants with closure; includes associated periodontal surgical procedures (e.g., gingivectomy/gingivoplasty, crown lengthening, surgical revision)

Flap and debridementElevation of a full‑thickness flap and debridement of the osseous defect prior to recontouring

Osseous recontouringReshaping of horizontal and/or vertical osseous defects to manage periodontal disease-related bone loss

Peri‑implant applicabilityMay be performed around dental implants; implants are considered similarly to natural teeth for quadrant surgery

OpenPayer

Osseous Surgery (Periodontal)

Coverage Criteria

Coding and Procedural Requirements

Provider Actions and Documentation Requirements

Definitions

Background