CurrentBlue Cross Blue Shield - NevadaPolicy 04-301

Scaling and Root Planing

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Clinical criteria and documentation requirements for review of periodontal scaling and root planing services for Blue Cross Blue Shield - Nevada members; applies to dental providers seeking coverage determination for these procedures.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyScaling and Root Planing

Policy CodePolicy 04-301

Change TypeNo material changes

Effective Date

Last ReviewDec 4, 2020

Next Review Date

Key ActionProvide full‑mouth radiographs (or panoramic with bitewings) labeled and dated within 12 months and 6‑point periodontal charting to support coverage review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 mmmin pocket depth

D4341/D4342primary CDT codes

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CurrentBlue Cross Blue Shield - NevadaPolicy 04-301

Scaling and Root Planing

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Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyScaling and Root Planing

Policy CodePolicy 04-301

Change TypeNo material changes

Effective Date

Last ReviewDec 4, 2020

Next Review Date

Key ActionProvide full‑mouth radiographs (or panoramic with bitewings) labeled and dated within 12 months and 6‑point periodontal charting to support coverage review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 mmmin pocket depth

D4341/D4342primary CDT codes

Coverage Criteria

Medical necessity criteria

Covered when ALL of the following are met:

Diagnostic documentation: Full mouth radiographs and/or panoramic radiograph including bitewings (labeled and dated within 12 months) AND 6-point periodontal pocket depth charting (labeled and dated within 12 months)radiographs and charting dated within 12 months

See Documentation Criteria #1

Clinical findings: Teeth to be treated demonstrate periodontal pocket depths >= 4 mm (partial quadrant: at least 1 tooth with >= 4 mm; full quadrant: at least 4 teeth with >= 4 mm), bleeding on probing, and demonstrable radiographic alveolar bone loss (bone level > 1.5 mm apical to the CEJ)pocket depth >= 4 mm; bone loss > 1.5 mm apical to CEJ

Applicable diagnoses listed below

Procedure requirements: Procedure performed using appropriate instrumentation (hand or ultrasonic) and with local anesthesia administered by intramucosal injection (topical or subgingival anesthetic does not qualify)local anesthesia via intramucosal injection

Duration of treatment times may be requested for review; additional documentation may be requested when more than two quadrants are treated in one appointment

Acceptable diagnoses: Chronic periodontitis; localized and generalized aggressive periodontitis; localized and generalized periodontitis as a manifestation of systemic disease; necrotizing periodontal diseases

These diagnoses qualify for payment

Procedures performed solely for gingival diseases — whether plaque-induced or non-plaque-induced — do not meet the payment criteria in this policy and are not eligible for coverage.

Scaling and debridement performed on dental implants is not separately payable; such services are considered inclusive with D4341 and D4342 and should be billed accordingly.

Treatment directed at gingival disease without periodontal pocketing (plaque-induced or non–plaque-induced gingival disease) does not qualify for payment under this policy.

Coding

CDT procedure codes includedCDT

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

CDT procedure codes included (duplicate grouping removed)CDT

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

inv-06: Periodontal pocket depth — threshold value

Minimum pocket depthAt least 4 millimeters (>= 4 mm)

Clinical contextProcedure indicated when epithelial attachment migration has formed periodontal pockets >= 4 mm

Quadrant requirement referencePartial or full quadrant definitions use the 4 mm pocket depth threshold

inv-07: Radiograph recency requirement

Radiograph recency requirementFull mouth radiographs and/or panoramic with bitewings must be labeled and dated within 12 months of the submitted procedure

Documentation typeFull mouth radiographic images and/or a panoramic radiographic image including bitewings

Provider Actions & Documentation Requirements

Prior Authorization

Documentation required for review / possible prior authorization

Review may be performed and additional documentation may be requested for scaling and root planing services, particularly when more than two quadrants are treated in a single appointment. For payment consideration, documentation of pocket depths, radiographic bone loss, and administration of local anesthesia by intramucosal injection is required.

Additional clinical and/or administrative documentation may be requested when more than two quadrants are performed during one appointment.
Documentation should include pocket depths, radiographic evidence of bone loss, and proof of local anesthesia administered by intramucosal injection.

Note

Submit complete supporting records with the claim

Ensure required diagnostic and supportive records are submitted with the claim; the policy lists specific imaging and charting requirements and notes that treatment duration and post-therapy evaluations may be requested for individual case review.

Background

Scaling and root planing is a nonsurgical, therapeutic periodontal procedure that involves instrumentation of crown and root surfaces to remove plaque, calculus, diseased cementum and toxins. It is indicated when there is migration of the epithelial attachment resulting in periodontal pockets of at least 4 mm and is typically performed using hand or ultrasonic instrumentation under local anesthesia administered by intramucosal injection.

Definitions

inv-14: Scaling and root planing — definition (non-surgical instrumentation to remove plaque, calculus, diseased cementum)

DefinitionNon-surgical instrumentation of crown and root surfaces to remove plaque, calculus, and diseased cementum and dentin (may be permeated with calculus, toxins, and microorganisms)

PurposeTherapeutic procedure to treat periodontal disease where epithelial attachment migration has formed periodontal pockets of at least 4 mm

Technique and anestheticPerformed using hand and/or ultrasonic instrumentation and with local anesthetic (intramucosal injection)

inv-15: Full vs partial quadrant — definitions and tooth-count thresholds

Partial quadrantAt least 1 tooth in the quadrant with pocket depth >= 4 mm

Full quadrant