ModifiedBlue Cross Blue Shield - WisconsinPolicy 04-202

Gingivectomy or Gingivoplasty

Defines clinical indications, contraindications, documentation requirements, limits, and coding guidance for coverage of gingivectomy and gingivoplasty dental procedures under the Plan's dental clinical policy.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyGingivectomy or Gingivoplasty

Policy CodePolicy 04-202

Change TypeClarified (minor editorial refinements; intent unchanged)

Effective DateJan 1, 2025

Next Review Date

Key ActionProviders must have current (within 12 months) dated 6-point periodontal charting and diagnostic quality pretreatment radiographs showing periapical area and alveolar crest to support medical necessity.

POLICY UPDATE CHANGES

Minor editorial refinements to description, clinical indications, criteria (line #15 added), and reference; intent unchanged.

>=5mmPocket depth threshold for coverage

2Quadrants limit per date of service

1 per [36/60] moFrequency limit per tooth/quadrant

12 monthsRecency required for charting and radiographs

Coverage Summary

This policy (Policy No. 04-202) provides coverage guidance for Gingivectomy or Gingivoplasty. The policy defines clinical indications, contraindications, documentation requirements, limits, and coding guidance for these procedures and takes a mixed coverage stance. The policy is effective 01/01/2025 with last review date 09/10/2024.

Thresholds and Quick Facts

Pocket depth threshold>= 5 mm (recorded on 6-point periodontal charting within 12 months)

Recency required for charting and radiographs12 months

Quadrants limit per date of serviceMaximum 2 quadrants per date of service

Frequency limit per tooth/quadrantGenerally limited to 1 procedure per [36/60] month period per single tooth or multiple teeth in same quadrant

Healing interval after nonsurgical therapy>= 4 weeks