CurrentBlue Cross Blue Shield - WisconsinPolicy 04-901

Periodontal Maintenance

Defines clinical indications and criteria for periodontal maintenance as a therapeutic, post‑treatment continuing care procedure following definitive periodontal therapy; includes documentation and coding guidance for dental review and utilization management. Applies to review of dental claims for periodontal maintenance to determine appropriateness and contractual coverage.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyPeriodontal Maintenance

Policy CodePolicy 04-901

Change TypeRevised (Annual Review)

Effective DateJan 1, 2022

Next Review DateN/A

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

POLICY UPDATE CHANGES

Policy labeled Revised with last review date 10/30/2021 and publish date 01/01/2022.

5Core clinical criteria items

5CDT codes listed

12Max continuous care interval (months)

Coverage Summary

This policy defines clinical indications and documentation/coding guidance for periodontal maintenance, a therapeutic post‑treatment continuing care procedure performed after definitive periodontal therapy. It is intended for use in utilization review and dental necessity determinations to assess whether periodontal maintenance meets contractual and generally accepted standards of dental practice. Applicable setting: ongoing periodontal maintenance provided as continuing care following active definitive periodontal therapy for the life of the dentition or implant placement.

Provider Actions & Prior Authorization

Prior Authorization

Letter of medical necessity for LACA

A letter of medical necessity is required for locally administered chemotherapeutic agents (LACA). Include CDT code D4381 when submitting prior authorization or documentation for LACA use.

D4381

Documentation Required

Document prior definitive periodontal therapy

Document prior definitive periodontal therapy to support periodontal maintenance eligibility. Required documentation must include dates of the definitive therapy and the specific treatments rendered.

Documentation Required

Continuous care interval documentation

Provide documentation of the history of periodontal therapy and evidence of continuous care within the preceding 12 months. Continuous care interval must not exceed 12 months.

Documentation Required

Include post-therapy evaluations

Document post-initial therapy evaluations and treatment planning recommendations as integral components of periodontal maintenance. Include records of evaluations and any recommended treatment planning after completion of initial therapy.

Denial Risk

Denial risk if no prior periodontal disease

Claims for periodontal maintenance (D4910) may be denied if there is no documented history of periodontal disease requiring definitive periodontal treatment. Ensure documentation demonstrates prior periodontal disease and definitive treatment to avoid denial.

D4910

Coding

Relevant CDT codes (informational list)mixed

D4341	Four or more teeth per quadrant
D4342	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

Diagnosis codes referenceICD-10

See CDT code book

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

Background & Definitions

Periodontal maintenance is described as a lifelong, nonsurgical therapeutic phase of continuing care after active definitive periodontal therapy intended to remove etiologic factors (plaque, biofilm, adherent calculus, diseased cementum), involve instrumentation (including hand instrumentation), and monitor periodontal disease and conditions. This policy is used to guide utilization review and to determine dental necessity per contract requirements and generally accepted standards of dental practice, and includes documentation requirements such as history of prior definitive periodontal therapy (with dates and treatments) and continuous care intervals not exceeding 12 months. A letter of medical necessity is required for use of locally administered chemotherapeutic agents (LACA).

References: Multiple peer‑reviewed periodontal studies and American Academy of Periodontology position papers support the guidance summarized in this policy.

Term	Definition
Periodontal Maintenance
Nonsurgical, therapeutic continuing care following periodontal therapy involving instrumentation to remove plaque, biofilm, calculus, and diseased cementum and monitoring periodontal conditions for the life of the dentition or implant.
Locally Administered Chemotherapeutic Agents (LACA)
Antimicrobial agents delivered locally into diseased crevicular tissue; requires letter of medical necessity per policy.

Revision History

2021-10-30annual_reviewLatest

Policy labeled Revised with last review date 10/30/2021 and publish date 01/01/2022.

2022-01-01publish

Dental Clinical Policy publish date 01/01/2022.

2017-03-14revision_history

Initial revision history entry recorded (3/14/17).

2018-02-05revision_history

Revision entry 2/5/18: related dental policies, appropriateness and medical necessity.

2020-11-10annual_review

Revision entry 11/10/2020 noted as Annual Review.

2020-12-05annual_review

Revision entry 12/05/2020 noted as Annual Review.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyPeriodontal Maintenance

Policy CodePolicy 04-901

Change TypeRevised (Annual Review)

Effective DateJan 1, 2022

Next Review DateN/A

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

On This Page

OpenPayer

Periodontal Maintenance

Coverage Summary

Medically/Dentally Necessary (Periodontal Maintenance)

Not Appropriate / Exclusions

Provider Actions & Prior Authorization

Coding

Background & Definitions

Revision History