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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialEmpire Bluecross Periodontal Maintenance Coverage …
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    CurrentEmpire BluecrossPolicy 04-901

    Periodontal Maintenance

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    Defines clinical indications, criteria, and applicable procedure codes for periodontal maintenance as continuing therapeutic care following definitive periodontal therapy; intended for dental providers and utilization reviewers of Empire Bluecross plans.

    Policy Summary
    PayerEmpire Bluecross
    PolicyPeriodontal Maintenance
    Policy CodePolicy 04-901
    Change TypeNo material change
    Effective DateJan 1, 2022
    Last ReviewOct 30, 2021
    Next Review Date
    Key ActionVerify prior definitive periodontal therapy with dates and specific treatments when submitting periodontal maintenance for coverage.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    D4910Primary CDT code for periodontal maintenance
    12 monthsMax continuous care interval
    D4341, D4342, D4381, D4999

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Additional CDT codes
    Life of dentitionMaintenance scope

    Coverage Criteria

    Medical necessity criteria for periodontal maintenance

    Covered when ALL of the following are met

    Core indications: 1) History of periodontal therapy and continuous care not exceeding 12 months; 2) Prior history of definitive periodontal therapy with dates and specific treatment rendered; 3) Periodontal maintenance is provided following therapeutic periodontal treatment as continuing care for a diagnosis of periodontal disease; 4) Post-initial therapy evaluations and treatment planning recommendations following completion of periodontal maintenance are considered integral components of this procedure.12 months

    Periodontal maintenance is therapeutic (not prophylactic), involves instrumentation of crown and root structures to remove plaque, calculus and diseased cementum, and continues for the life of the dentition or implants.

    A periodontal maintenance procedure is considered not appropriate when there is no history of periodontal disease requiring definitive periodontal treatment. This aligns with the policy criteria that maintenance follows prior therapeutic periodontal care and is not intended as initial treatment for patients without such a history.

    Use of periodontal maintenance is considered not medically appropriate without evidence of prior definitive periodontal therapy. The policy requires documentation of a prior history of definitive periodontal therapy with dates and specific treatments rendered; absence of that history makes maintenance procedures inappropriate.

    Procedure Codes

    CDT codes referencedCDT
    D4341Four or more teeth per quadrant
    D4342Less than three teeth per quadrant
    D4381Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
    D4910Periodontal maintenance
    D4999Unspecified periodontal procedure, by report

    Provider Actions & Documentation

    Prior Authorization

    Code listing — check member contract for authorization

    Check the member's contract benefits in effect at the time of service to determine whether periodontal maintenance services require prior authorization or are covered. Inclusion of procedure codes here is informational and does not guarantee coverage or reimbursement.

    • Affected codes: D4341, D4342, D4381, D4910, D4999
    • Action: Verify member-specific prior authorization requirements and benefit limits before providing or billing periodontal maintenance
    Step Therapy

    Therapy sequence

    Periodontal maintenance is indicated only after completion of definitive (active) periodontal therapy and is an ongoing phase of care to maintain periodontal health. It is therapeutic (not prophylactic), may continue for the life of the dentition or implants, and typically occurs at periodic intervals (not exceeding 12 months between continuous care episodes per the criteria). Documentation should demonstrate prior definitive therapy with dates and treatments rendered and that maintenance visits are part of a sequence of care following initial therapy.

    Background

    Periodontal maintenance is a nonsurgical, therapeutic phase of care performed after active periodontal therapy to preserve periodontal health. The policy emphasizes that maintenance is part of an ongoing program of care following definitive periodontal treatment, requires prior history of therapy with dates and specifics, and includes post-initial therapy evaluations and treatment planning as integral components. Additionally, for locally administered chemotherapeutic agents (LACA), a letter of medical necessity is required.

    Definitions

    Periodontal maintenance
    DefinitionNonsurgical therapeutic treatment following definitive periodontal therapy that continues for the life of the dentition or implants to remove etiologic factors and monitor periodontal disease status.
    Therapeutic intentConsidered therapeutic (not prophylactic) and constitutes continuing treatment for patients with a diagnosis of periodontal disease.
    Primary objectivesReduce or eliminate causative factors (plaque, biofilm, calculus, diseased cementum) and maintain periodontal health achieved after active therapy.
    Clinical activitiesInstrumentation of tooth crown and root structures, including hand instrumentation to remove adherent deposits and diseased cementum.
    DurationContinues for the life of the dentition or any implant placement as ongoing periodic care.
    Policy Summary
    PayerEmpire Bluecross
    PolicyPeriodontal Maintenance
    Policy CodePolicy 04-901
    Change TypeNo material change
    Effective DateJan 1, 2022
    Last ReviewOct 30, 2021
    Next Review Date
    Key ActionVerify prior definitive periodontal therapy with dates and specific treatments when submitting periodontal maintenance for coverage.
    SourceLink
    On This Page
    Coverage CriteriaProcedure CodesProvider Actions & DocumentationBackgroundDefinitions
    • Periodontal maintenance is therapeutic and occurs only after definitive periodontal therapy
    • Maintain records of dates and specific definitive periodontal procedures performed prior to maintenance
    • Post-initial therapy evaluations and treatment planning are integral to periodontal maintenance
    • For locally administered chemotherapeutic agents (LACA), include a letter of medical necessity when applicable
    Documentation Required

    Required documentation & denial risk

    A periodontal maintenance procedure is not appropriate when there is no prior history of periodontal disease requiring definitive periodontal treatment. Ensure the chart contains documentation of the diagnosis, prior definitive therapy (with dates and specific treatments), and ongoing monitoring notes to support medical necessity.

    • Required documentation: prior definitive periodontal therapy with dates and specific treatments rendered
    • Include post-therapy evaluations and treatment planning notes as part of the maintenance episode
    • If LACA used, attach a letter of medical necessity