CurrentBlue Cross Blue Shield - NevadaPolicy 04-301

Scaling and Root Planing Guideline 04-301

Policy governs clinical documentation and coverage criteria for periodontal scaling and root planing (D4341, D4342) as medically/dentally necessary treatment for periodontal disease under the plan. It specifies diagnostic requirements, clinical indications, acceptable diagnoses, exclusions, and coding guidance for review and payment determination.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyScaling and Root Planing Guideline 04-301

Policy CodePolicy 04-301

Change TypeRevised (10/28/2022)

Effective DateJan 1, 2023

Next Review Date

Key ActionSubmit current (within 12 months) pretreatment full mouth radiographs/panoramic with bitewings and 6-point periodontal charting for review.

SourceLink

POLICY UPDATE CHANGES

Policy was revised (status Revised) with latest review date 10/28/2022 and published effective 01/01/2023.

2Primary CDT procedural codes listed

>=4 mmPocket depth threshold for coverage

>1.5 mmRadiographic bone loss threshold

12 monthsRecency requirement for radiographs and charting

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Coverage Summary

Policy governs clinical documentation and coverage criteria for periodontal scaling and root planing (CDT codes D4341 and D4342) as medically/dentally necessary treatment for periodontal disease under the plan. It specifies diagnostic requirements (including current radiographs and 6-point periodontal charting within 12 months), clinical indications, acceptable diagnoses, exclusions, and coding guidance for review and payment determination.

Scaling and root planing is a nonsurgical periodontal therapy performed to remove plaque, calculus and diseased cementum from crown and root surfaces to treat periodontal pockets of at least 4 mm. The procedure is technique-sensitive, typically done with hand and/or ultrasonic instrumentation and routinely performed using local anesthetic, and is considered therapeutic (not prophylactic).

Quick Facts and Coverage Thresholds

Periodontal pocket depth>= 4 mm

Bone loss> 1.5 mm apical to CEJ

Radiographs/charting recency12 months

Primary CDT procedural codes listed (informational)D4341, D4342

Medically/Dentally Necessary Criteria

Medically/Dentally Necessary Criteria for Scaling and Root Planing

Covered when ALL of the following are met:

ALL of the following

Documentation Criteria #1
- Current (within 12 months), dated, pretreatment full mouth radiographic images and/or a panoramic radiographic image including bitewings radiographs.
- Current (within 12 months), dated, pretreatment periodontal charting (6-point periodontal charting).
Teeth to be treated must demonstrate at least 4-millimeter pocket depths, bleeding on probing, with demonstrable radiographic evidence of bone loss (vertical or horizontal) of the alveolar crest.bone level > 1.5 mm apical to CEJ
Periodontal scaling and root planing requires administration of local anesthesia by intramucosal injection.
Topical anesthetics and subgingival preparations do NOT qualify as local anesthesia for these procedures.
Quadrant pocket rules
- Partial quadrant: at least 1 tooth with pocket depth >= 4 mm
- Full quadrant: at least 4 teeth with pocket depth >= 4 mm
Acceptable diagnoses
- Chronic periodontitis
- Localized aggressive periodontitis
- Generalized aggressive periodontitis
- Periodontitis as a manifestation of systemic disease (localized or generalized)
- Necrotizing periodontal diseases
Post-therapy and multi-quadrant notes: Post-initial therapy evaluations and treatment planning recommendations following completion of scaling and root planing are considered integral components of this procedure.
Documentation of duration of treatment times may be required for individual case review.
Additional clinical and/or administrative documentation may be requested when more than two quadrants of scaling and root planing are performed during one appointment.

Not Covered / Exclusions

Not covered when ANY of the following apply:

ANY of the following

Gingival diseases (plaque induced or non-plaque induced) — do not qualify for payment.
Procedures coded as scaling and debridement of implants are considered inclusive with D4341 and D4342.
Implant scaling is not separately billable when D4341/D4342 are reported.

Provider Actions / Documentation Requirements

Documentation Required

Provide current radiographs and periodontal charting

Submit current (within 12 months), dated pretreatment full mouth radiographic images and/or a panoramic radiographic image including bitewings, and current (within 12 months) dated pretreatment 6‑point periodontal charting as part of the diagnostic information for review.

Full mouth radiographs or panoramic with bitewings (dated, within 12 months)
6‑point periodontal charting (dated, within 12 months)

Documentation Required

Document pocket depths and bleeding on probing

Include periodontal probing depths showing pockets of 4 mm or greater, documentation of bleeding on probing, and radiographic evidence of alveolar bone loss. Bone loss is defined as bone level greater than 1.5 mm apical to the cementoenamel junction (CEJ).

Probing depths ≥ 4 mm
Bleeding on probing
Radiographic bone loss > 1.5 mm apical to CEJ

Documentation Required

Document anesthetic administration

Record that local anesthesia was administered by intramucosal injection. Note that topical anesthetics and anesthetic preparations placed subgingivally do not qualify as the required local anesthesia for scaling and root planing.

Local anesthesia administered by intramucosal injection (required)
Topical or subgingival anesthetics do not satisfy the anesthesia requirement

Documentation Required

Document duration and quadrant counts for extensive treatment

Provide duration of treatment times if requested for individual case review. When more than two quadrants of scaling and root planing are performed during one appointment, include additional clinical and/or administrative documentation to support the extensive treatment.

Treatment duration (hours/minutes) — provide if requested
Additional documentation when > 2 quadrants are treated in one appointment

Background & Evidence

Scaling and root planing is a nonsurgical, therapeutic periodontal procedure that involves instrumentation of tooth crown and root surfaces to remove plaque, biofilm, adherent calculus deposits, and diseased cementum that may be permeated with microorganisms and toxins. It is performed to treat periodontal disease where epithelial attachment loss has produced periodontal pockets of at least 4 mm.

The procedure is demanding and technique-sensitive, performed with hand instruments and/or ultrasonic scalers, and is routinely performed utilizing local anesthesia by intramucosal injection; topical or subgingival anesthetic preparations do not qualify as the required local anesthesia.

Scaling and root planing is therapeutic rather than prophylactic and involves removal of cementum and dentin permeated by calculus, toxins, and microorganisms to address mild to severe periodontal disease.

Evidence note: Smiley CJ et al., J Am Dent Assoc. 2015 Jul;146(7):508-24 — systematic review and meta-analysis on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing (with or without adjuncts).

Definitions

Bone lossBone level greater than 1.5 mm apical to the cementoenamel junction (CEJ).

Full quadrantAt least 4 teeth in the quadrant have pocket depths >= 4 mm.

Partial quadrantAt least 1 tooth in the quadrant has a pocket depth >= 4 mm.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyScaling and Root Planing Guideline 04-301

Policy CodePolicy 04-301

Change TypeRevised (10/28/2022)

Effective DateJan 1, 2023

Next Review Date

Key ActionSubmit current (within 12 months) pretreatment full mouth radiographs/panoramic with bitewings and 6-point periodontal charting for review.

SourceLink

On This Page

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

OpenPayer

Scaling and Root Planing Guideline 04-301

Coverage Summary

Medically/Dentally Necessary Criteria

Not Covered / Exclusions

Coding

Provider Actions / Documentation Requirements

Background & Evidence

Revision History