CurrentDelta Dental of OhioPolicy 282.31.v2

Clinical Criteria for Periodontal Osseous Surgery

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Establishes clinical criteria used to evaluate the medical necessity and clinical appropriateness of periodontal osseous surgery when a member’s dental plan requires clinical review.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Periodontal Osseous Surgery

Policy CodePolicy 282.31.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionWhen required by the dental plan, submit clinical and radiographic documentation supporting the medical necessity and clinical appropriateness of osseous surgery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D4261Applicable CDT procedure code

5 mmQualifying periodontal pocket depth

4 teethMinimum eligible teeth per quadrant

12 monthsMaximum charting age

1-, 2-, or 3-wall

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CurrentDelta Dental of OhioPolicy 282.31.v2

Clinical Criteria for Periodontal Osseous Surgery

Customize your policy alerts

Sign up for deltadentalofohio Policy 282.31.v2 alerts

Get alerted when Policy 282.31.v2 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Establishes clinical criteria used to evaluate the medical necessity and clinical appropriateness of periodontal osseous surgery when a member’s dental plan requires clinical review.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Periodontal Osseous Surgery

Policy CodePolicy 282.31.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionWhen required by the dental plan, submit clinical and radiographic documentation supporting the medical necessity and clinical appropriateness of osseous surgery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D4261Applicable CDT procedure code

5 mmQualifying periodontal pocket depth

4 teethMinimum eligible teeth per quadrant

12 monthsMaximum charting age

1-, 2-, or 3-wall

Suitable bone defect patterns

Medical Necessity and Clinical Appropriateness

Generally Accepted Indications

Osseous surgery is generally indicated when <strong>ONE</strong> of the following conditions is documented:

ONE of the following

Non-surgical therapy or non-osseous flap surgery has failed to control periodontal disease, including generalized infrabony pocketing, furcation involvement, or clinical loss of attachment.
Osseous resection surgery can be expected to create physiologic bone contours that reduce or eliminate periodontal pockets and form minimal sulcus depth conducive to effective oral hygiene and periodontal maintenance.
Early to moderate bone loss presents with one-, two-, or three-wall bony defects and/or incipient furcation involvement, conditions generally suitable for osseous resective surgery.

Additional Coverage Criteria

Depending on the individual patient's condition and circumstances, the following additional criteria may be applied for coverage determinations:

Unless otherwise established by a dental benefit program, osseous surgery is eligible for benefit coverage for the treatment of natural teeth only.

Periodontally involved teeth generally qualify when ALL of the following are documented

Periodontal pocket depths of at least 5 millimeters.
Furcation involvement.
Radiographic evidence of bone deformity.

Periodontal procedures submitted by quadrant must have at least 4 teeth eligible for treatment.

Exceptions and Governing Criteria

The following exceptions and governing requirements apply when determining medical necessity and clinical appropriateness:

Government regulations or the provisions of a member's dental plan that define when a dental procedure may be considered medically necessary and clinically appropriate with respect to benefit coverage may take precedence over these clinical criteria.

When dental benefit programs establish program-specific criteria defining when osseous surgery is medically necessary and eligible for benefit coverage, or establish other limitations on osseous surgery coverage, Delta Dental of Ohio will apply those criteria when evaluating osseous surgery.

For patients who do not meet the published qualifying criteria for osseous surgery, Delta Dental of Ohio will consider documentation from relevant clinicians explaining the necessity of covering osseous surgery for conditions not included in the criteria.

Osseous surgery may be considered not medically necessary, inadvisable, or deficient in clinical quality when:

- There is no loss of supporting alveolar bone around the teeth.

- The condition can be appropriately managed with closed non-surgical treatment or surgical regenerative therapy.

- Resective osseous surgery would unacceptably compromise esthetics or increase tooth mobility.

Periodontal surgery may be inadvisable in patients with medical conditions or treatment histories including, but not limited to:

- A history of bisphosphonate treatment.

- Chemotherapeutic treatment of the head and neck.

- Radiation therapy of the head and neck.

Osseous surgery may also be considered not medically necessary, inadvisable, or deficient in clinical quality when:

- It is performed on a tooth with a hopeless periodontal, endodontic, or structural prognosis.

- It is repeated in the absence of periodontal disease progression.

- The patient is non-compliant with oral hygiene procedures and supportive care.

Procedure Codes and Qualifying Parameters

Applicable Dental Procedure CodesCDT

D4261

Contiguous teeth or tooth bounded spaces per quadrant osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant

Periodontal pocket depth

Minimum pocket depthAt least 5 millimeters

Additional periodontal findingFurcation involvement must be documented

Radiographic findingRadiographic evidence of bone deformity must be documented

Eligible teeth per quadrant

Minimum eligible teethAt least 4 teeth

Submission basisThe requirement applies to periodontal procedures submitted by quadrant

Eligibility standard

Submission Requirements and Benefit Determination Risks

Prior Authorization

Clinical Review May Be Required

When the member’s dental plan requires Delta Dental of Ohio to determine whether osseous surgery is medically necessary and clinically appropriate, the treating practitioner must document a generally accepted indication in the patient’s dental record. Government regulations and the member’s dental-plan provisions defining medical necessity and clinical appropriateness may take precedence over these criteria.

Documentation Required

Submit Diagnostic Radiographs

Submit preoperative diagnostic-quality radiographs with the claim, including bitewing images showing the teeth in the areas where osseous surgery is planned.

Documentation Required

Submit Photographs When Needed

Clinical Background

Periodontitis can cause loss of connective tissue attachment and supporting alveolar bone, producing uneven bony contours and deep periodontal pockets. These pockets can make effective oral hygiene and periodontal maintenance difficult. Periodontal osseous surgery is a resective procedure that modifies alveolar bone contours to create a more physiologic relationship with the gingiva, reduce or eliminate deep pockets, and facilitate plaque control and ongoing periodontal maintenance.

Terminology

Ostectomy

DefinitionRemoval of underlying deformities from bone that directly supports the teeth

Bone involvedAlveolar bone directly supporting the teeth

Role in surgeryA bone-removal technique used during resective osseous surgery

Osteoplasty

DefinitionReshaping of nonsupporting bone to provide a more physiologic form for the overlying gingiva

Bone involvedNonsupporting alveolar bone

PurposeTo provide a more physiologic form for the overlying gingiva

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Periodontal Osseous Surgery

Policy CodePolicy 282.31.v2

Change TypeNo material change

Effective DateJun 21, 2025

Next Review DateN/A

Key ActionWhen required by the dental plan, submit clinical and radiographic documentation supporting the medical necessity and clinical appropriateness of osseous surgery.

SourceLink

On This Page

The teeth must be eligible for treatment

Preoperative periodontal charting

Maximum charting ageWithin 12 months of treatment

Charting typePreoperative six-point periodontal pocket depth charting

Required charting informationClinical attachment loss, tooth mobility, bleeding on probing, and furcation involvement

Submit intraoral photographs of the involved areas when radiographs do not adequately demonstrate the need for the submitted services.

Documentation Required

Submit Periodontal Charting

Submit preoperative six-point periodontal pocket-depth charting performed within 12 months of treatment. The charting must document clinical attachment loss, tooth mobility, bleeding on probing, and furcation involvement.

Documentation Required

Document Diagnostic Rationale

The dental record must explain the diagnostic rationale for performing osseous surgery, consistent with the patient’s clinical record, including supporting information from the patient’s dental and medical histories.

Documentation Required

Provide Additional Clinical Information

Delta Dental of Ohio may request other clinical information relevant to the patient’s care when needed to make a coverage decision based on medical necessity or clinical appropriateness.

Denial Risk

Conditions That May Result in Disapproval

Depending on the clinical circumstances, osseous surgery may be considered not medically necessary, inadvisable, or deficient in clinical quality and may be disapproved when any of the following apply:

There is no loss of supporting alveolar bone around the teeth.
The condition can be appropriately managed with closed non-surgical treatment or surgical regenerative therapy.
Resective osseous surgery would unacceptably compromise esthetics or increase tooth mobility.
The treated tooth has a hopeless periodontal, endodontic, or structural prognosis.
Osseous surgery is repeated without progression of periodontal disease.
The patient is non-compliant with oral hygiene procedures and supportive care.

Denial Risk

Contraindicating Medical History

Periodontal surgery may be considered inadvisable when the patient has relevant medical conditions or treatment history, including a history of bisphosphonate treatment or chemotherapy or radiation therapy of the head and neck.

Billing Rule

Benefit Eligibility Limitations

Unless a dental benefit program establishes otherwise, osseous surgery is eligible for benefit coverage for natural teeth only. Additional program and treatment-unit limitations may apply.

Periodontally involved teeth generally qualify when documentation shows periodontal pocket depths of at least 5 millimeters, furcation involvement, and radiographic evidence of bone deformity.
A quadrant-submitted periodontal procedure must include at least 4 teeth eligible for treatment.
Delta Dental of Ohio applies program-specific medical-necessity, eligibility, and coverage limitations when the applicable dental benefit program establishes them.

Denial Risk

Failure to Meet Qualifying Criteria

Osseous surgery is generally supported when non-surgical therapy or non-osseous flap surgery has failed to control periodontal disease; when resection can create physiologic bone contours that reduce or eliminate periodontal pockets and support effective hygiene and maintenance; and when early-to-moderate bone loss presents with one-, two-, or three-wall defects and/or incipient furcation involvement. If published qualifying criteria are not met, submit documentation from relevant clinicians explaining why coverage is necessary for the condition.

If the practitioner cannot provide the required clinical and radiographic information, benefit payment may be disapproved.
The submitted record should substantiate the qualifying clinical findings and the proposed treatment plan.

Periodontal osseous surgery

Procedure typeA resective procedure

Surgical modificationSurgically modifies the contours of alveolar bone through reshaping

Clinical objectiveAchieves a more physiologic form relative to gingival contours and facilitates control of periodontitis