CurrentBlue Cross Blue Shield - WisconsinPolicy 04-301

Scaling and Root Planing

Governs clinical review criteria and documentation requirements used by the plan to determine medical/dental necessity for periodontal scaling and root planing for plan members.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyScaling and Root Planing

Policy CodePolicy 04-301

Change TypeNo material change

Effective Date01/01/2022

Next Review DateN/A

Key ActionSubmit full-mouth radiographs and 6-point periodontal charting (dated within 12 months) when requesting review or prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 mmmin pocket depth (eligibility)

D4341/D4342primary CDT codes

12 momax age of docs

1+ / 4+tooth count thresholds

Coverage Criteria for Scaling and Root Planing

Covered when ALL of the following are met

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Diagnostic documentation: Full mouth radiographs and/or a panoramic radiograph including bitewings, and 6‑point periodontal pocket depth charting, labeled and dated within 12 months, are provided.periodontal charting and radiographs ≤ 12 months

Documentation Criteria #1

Clinical findings: Treated teeth demonstrate pocket depths ≥ 4 mm with bleeding on probing and radiographic evidence of alveolar bone loss (bone level > 1.5 mm apical to the CEJ).pocket depth ≥ 4 mm; bone loss >1.5 mm apical to CEJ

Criteria items 2 and 2 (bone loss definition)

Anesthesia: Local anesthesia administered by intramucosal injection for the procedure.

Topical or subgingival anesthetic preparations do not qualify as local anesthesia for scaling and root planing (Criteria item 3)

Quadrant tooth-count: Partial quadrant: at least 1 tooth in the quadrant with pocket depth ≥ 4 mm; Full quadrant: at least 4 teeth in the quadrant with pocket depths ≥ 4 mm.1+ teeth (partial) or 4+ teeth (full) per quadrant

Criteria item 8

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

Criteria item 9

Coding and Procedure Codes

CDT codes referencedCDT

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.

Periodontal pocket depth — eligibility threshold

Minimum pocket depth>= 4 mm

Clinical finding requiredTeeth to be treated must demonstrate at least 4-mm pocket depths with bleeding on probing

Radiographic correlationDemonstrable alveolar bone loss (bone level > 1.5 mm apical to CEJ) required

Documentation timeframePeriodontal charting must be labeled and dated within 12 months (see Documentation criteria #1)

Provider Documentation and Billing Actions

Documentation Required

Diagnostic documentation required for review

In order to perform review of scaling and root planing, diagnostic information is required. Provide full-mouth radiographs and/or a panoramic image including bitewings, and 6-point periodontal pocket depth charting; all images/charting must be labeled and dated within 12 months of the submitted procedure.

Full mouth radiographic images and/or panoramic radiograph including bitewings; labeled and dated (within 12 months)
Periodontal charting: 6-point pocket depth charting; labeled and dated (within 12 months)

Note

Benefit and coding disclaimer

Claims may be denied if the service or code is not a covered benefit under the member's contract. Codes listed in this document are informational only and do not guarantee coverage or reimbursement.

Denial Risk

Gingival diseases denial risk

Gingival diseases — whether plaque-induced or non–plaque-induced — do not qualify for payment and may be denied.

Documentation Required

Adjunctive documentation

Additional documentation may be requested during case review, including documentation of treatment duration for scaling and root planing, post-initial therapy evaluations, and treatment planning recommendations. More documentation may be required when more than two quadrants are treated in one appointment.

Documentation of treatment duration for periodontal scaling and root planing may be requested
Post-initial therapy evaluations and treatment planning recommendations are integral and may be requested
Additional clinical/administrative documentation may be requested for >2 quadrants treated in one appointment

Step Therapy

Step therapy not applicable

Step therapy is not applicable — no step therapy sequencing is described in this policy.

Billing Rule

Anesthesia documentation

Local anesthesia for scaling and root planing must be administered by intramucosal injection. Topical anesthetics or subgingival anesthetic preparations do not qualify as local anesthesia for billing purposes.

Background

Scaling and root planing is a nonsurgical therapeutic periodontal procedure involving instrumentation of crown and root surfaces with hand and/or ultrasonic instruments under local anesthesia to remove plaque, calculus, and diseased cementum and dentin. The goal is to reduce microbial load and periodontal pocket depths in teeth that meet clinical criteria, typically where epithelial attachment migration has produced pockets of >= 4 mm.

The procedure is technique-sensitive and time-consuming, generally performed quadrant by quadrant. It may be documented and billed as D4341 for four or more teeth per quadrant or D4342 for one to three teeth per quadrant, with quadrant classification based on tooth counts meeting the pocket-depth threshold (partial quadrant: 1+ tooth; full quadrant: 4+ teeth).

Definitions

Scaling and root planing — definition & procedure

DefinitionNonsurgical instrumentation of crown and root surfaces to remove plaque, calculus, and diseased cementum and dentin using hand and/or ultrasonic instruments under local anesthesia.

PurposeTherapeutic (not prophylactic) procedure to treat periodontal disease by reducing pocket depth and microbial load.

Typical techniquePerformed with hand and/or ultrasonic scalers; procedure is technique-sensitive and time-consuming.

AnesthesiaLocal anesthesia is required and administered by intramucosal injection; topical or subgingival preparations do not qualify.

Full quadrant vs partial quadrant — tooth count thresholds

Full quadrant thresholdAt least 4 teeth in the quadrant with pocket depths >= 4 mm

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

Quadrant counting noteQuadrant determination is based on teeth demonstrating pocket depths of 4 mm or more