CurrentBlue Cross Blue Shield - WisconsinPolicy 04-208

Periodontal Surgical Procedures, miscellaneous

Defines clinical indications, documentation, limitations, frequency and benefit determination rules for miscellaneous periodontal surgical procedures for Blue Cross Blue Shield - Wisconsin dental plans; applies where group contract benefits permit coverage and requires review per contract standards.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyPeriodontal Surgical Procedures, miscellaneous

Policy CodePolicy 04-208

Change TypeRevised (annual review)

Effective DateJan 1, 2023

Next Review Date

Key ActionProvide labeled and dated 6-point periodontal pocket depth charting and current pretreatment radiographs with documentation of pre and post non-surgical therapy and completion date of initial therapy.

POLICY UPDATE CHANGES

Policy status marked Revised with last review date 10/28/2022 and publish date 01/01/2023.

2Quadrant limit per date of service

>=5mmPocket depth threshold for coverage

36 monthsTypical frequency limit per quadrant

2023-01-01Publish Date

Coverage Summary

Policy provides guidance to determine dental medical necessity for miscellaneous periodontal surgical procedures per group contract terms, requiring that services meet generally accepted standards of dental practice and be supported by appropriate documentation; the plan performs reviews to ensure services are appropriate, not primarily cosmetic, and that coverage is dependent on the member's contract. This policy was last reviewed 10/28/2022 and published 01/01/2023.

Key thresholds and dates

Periodontal pocket depth>= 5 mm

Radiograph recencyCurrent (within 12 months)

Periodontal charting recencyLabeled and dated within 12 months

Minimum healing after initial therapy>= 4 weeks

Quadrant limit per date of service<= 2 quadrants (exceptions case-by-case)

Procedure frequency per quadrantGenerally limited to once every 36 months (group contract dependent)

Publish Date01/01/2023

Medical-Necessity Criteria

General Coverage Conditions / Documentation Requirements

Covered when ALL of the following are met:

ALL of the following

Periodontal charting is labeled and dated within 12 months of submitted procedurewithin 12 months
Refer to required 6-point charting
6-point periodontal pocket depth charting
Pre and post non-surgical periodontal therapy documented
Current (within 12 months), diagnostic quality, dated, pretreatment radiographic images demonstrating either horizontal and/or vertical osseous defectswithin 12 months
Completion of initial periodontal therapy (e.g. scaling and root planing) with a minimum of four weeks prior to any surgical treatment to allow for healing and assessment>= 4 weeks
Procedure limited to natural teeth only
Limited to periodontal pocket depth recordings of 5mm or greater>= 5 mm
Periodontal surgical procedures will be limited to two quadrants per date of service (exceptions case-by-case)<= 2 quadrants per date of service
Exceptions allowed on case-by-case basis
Only teeth with favorable periodontal outcomes will be considered for benefit
Benefits are group contract dependent; refer to member's contract
Generally limited to one periodontal surgical procedure per quadrant and generally once every 36 months

Indications and Non-indications — General Periodontal Surgery

Covered when ANY of the indicated clinical situations are present and general coverage conditions are met; Not covered when any NOT-indicated conditions apply:

Indicated when

To remove enlarged gingival tissue and supporting bone in an otherwise periodontally healthy area to provide an anatomically correct gingival relationship
To allow proper contour of restoration in an otherwise periodontally healthy area
To allow management of a fractured tooth in which the fracture extends subgingivally in an otherwise periodontally healthy area

Not indicated when

Solely for cosmetic/aesthetic purposes

Revision / Surgical Refinement Procedures

Conditions for coverage and disallowance/denial related to refinement procedures:

Indicated when

To refine the results of a previously provided surgical procedure
To modify irregular contours of hard or soft tissue

Not indicated when

Second stage implant surgery, membrane removal, or redoing a failing soft tissue graft

Billing outcome rules

When billed within the plan frequency limitations of the initial surgical procedure by the same dentist/dental office, the procedure is DISALLOWED

Procedures Adjacent to Edentulous/Terminal Tooth Areas

Coverage conditions and exclusions specific to surfaces adjacent to edentulous/terminal tooth areas:

ALL of the following

Presence of active periodontal disease and moderate to deep probing depths (greater than 5mm) on a surface adjacent to an edentulous/terminal tooth area> 5 mm
Need for increased access to root surface when previous non-surgical attempts have been unsuccessful on a surface adjacent to an edentulous/terminal tooth area

Not indicated when

Solely for cosmetic/aesthetic purposes
Patients who have been non-compliant with previous periodontal therapies

Provider Actions & Billing Guidance

Documentation Required

Submit periodontal charting and radiographs

Provide labeled and dated 6-point periodontal pocket depth charting and current (within 12 months) diagnostic quality pretreatment radiographs demonstrating osseous defects; include documentation of pre and post non-surgical therapy and completion date of initial therapy.

6-point periodontal pocket depth charting (labeled and dated within 12 months)
Current (within 12 months), diagnostic quality, dated pretreatment radiographs showing horizontal and/or vertical osseous defects
Documentation of pre- and post-nonsurgical periodontal therapy and completion date of initial therapy

Prior Authorization

Dental review required per contract

The plan performs review of periodontal surgical procedures to determine medical/dental necessity per contract. To determine if a dental review is required and for submission instructions, contact the customer service number on the member's ID card and submit supporting documentation for review as requested.

Billing Rule

Quadrant and frequency limits enforcement

Procedures are limited by quadrant and frequency per plan contract. Limits include allowing generally up to two quadrants per date of service and typical limits on repeat periodontal surgical procedures per quadrant.

Limit to two quadrants per date of service (exceptions considered case-by-case)
One periodontal surgical procedure per quadrant once every 36 months (group contract dependent; exceptions case-by-case)

Denial Risk

Cosmetic and non-compliant patient exclusions

Claims may be denied when the procedure is not indicated per policy. Common denial risks include procedures performed solely for cosmetic/aesthetic purposes, patients with uncontrolled underlying medical conditions, or patients who have been non-compliant with prior periodontal therapies.

Denied if the procedure is solely for cosmetic/aesthetic purposes
Denied for patients with an uncontrolled underlying medical condition
Denied for patients non-compliant with previous periodontal therapies

Background & Evidence

References: CDT 2023; American Academy of Periodontology guidelines; Proceedings of the World Workshop in Clinical Periodontics; ADA statements and other peer-reviewed sources. Definitions: Generally accepted standards of dental practice are standards based on credible peer-reviewed dental evidence, specialty society recommendations, views of recognized dentists in the clinical area, and other credible sources. Policy scope: coverage is group contract dependent and services performed in conjunction with non-covered services are also not covered; procedures billed within plan frequency limitations may be disallowed or denied depending on billing dentist/office. Documentation and contract requirements (e.g., labeled/dated periodontal charting, radiographs, completion of initial therapy) must be met for benefit consideration.

References: CDT 2023; American Academy of Periodontology guidelines; Proceedings of the World Workshop in Clinical Periodontics; ADA statements and other cited literature. Definitions: Generally accepted standards of dental practice—standards based on credible scientific evidence published in peer‑reviewed dental literature, specialty society recommendations/criteria, the views of recognized dentists in the relevant clinical area, and other credible sources.

D4230	Anatomical Crown Exposure four or more contiguous teeth
D4231	Anatomical Crown Exposure one to three contiguous teeth
D4268	Surgical Revision Procedure per tooth
D4274	Mesial/Distal Wedge Procedure single tooth

OpenPayer

Periodontal Surgical Procedures, miscellaneous

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions & Billing Guidance

Background & Evidence

Revision History