CurrentEmpire BluecrossPolicy 04-301

Scaling and Root Planing

Defines clinical indications, documentation requirements, and coding guidance for periodontal scaling and root planing services for Empire Bluecross members; applies to providers submitting requests for review of these dental procedures.

Policy Summary

PayerEmpire Bluecross

PolicyScaling and Root Planing

Policy CodePolicy 04-301

Change TypeNo material change

Effective DateJan 1, 2022

Next Review Date

Key ActionSubmit full mouth or panoramic radiographs and labeled 6-point periodontal pocket charting dated within 12 months to support medical necessity review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4minimum pocket depth (mm)

6-pointperiodontal charting

12 moradiograph validity

D4341/D4342referenced CDT codes

Coverage criteria for scaling and root planing

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Clinical indication: Periodontal disease with migration of the epithelial attachment causing periodontal pockets of at least 4 mm; nonsurgical periodontal scaling and root planing to remove plaque, calculus, and diseased cementum and dentin.pocket depth >= 4 mm

see periodontal definitions

Diagnostic documentation: Provide full‑mouth radiographic images and/or a panoramic radiographic image including bitewings, and labeled 6‑point periodontal pocket depth charting; all images and charting must be dated within 12 months of the submitted procedure.radiographs/charting <= 12 months old

radiographic evidence of bone loss required

Clinical signs: Teeth to be treated must demonstrate bleeding on probing and demonstrable radiographic bone loss (vertical or horizontal). Bone loss is defined as bone level greater than 1.5 mm apical to the CEJ. For a partial quadrant at least 1 tooth must have >= 4 mm pocket depth; for a full quadrant at least 4 teeth must have >= 4 mm pocket depths.partial: >=1 tooth; full: >=4 teeth

bone loss defined > 1.5 mm apical to CEJ

Procedure requirements: Administration of local anesthesia by intramucosal injection is required; topical or subgingival anesthetic preparations do not qualify as local anesthesia for scaling and root planing.local intramucosal anesthesia

treatment may use hand instruments and/or ultrasonic scalers

Coding guidance and code references

CDT codes referencedCDT

D1120	Prophylaxis adult
D4341	Periodontal scaling and root planing four or more teeth per quadrant
D4342	Periodontal scaling and root planing one to three teeth per quadrant
D4346	Scaling in presence of generalized moderate or severe gingival inflammation — full mouth after oral exam

Periodontal pocket depth — eligibility threshold

Minimum pocket depth>= 4 mm

Partial-quadrant requirementAt least 1 tooth in the quadrant with pocket depth >= 4 mm

Full-quadrant requirementAt least 4 teeth in the quadrant with pocket depths >= 4 mm

Clinical signs requiredBleeding on probing and demonstrable radiographic bone loss (vertical or horizontal)

Bone loss definitionBone level > 1.5 mm apical to the CEJ

Documentation, review, and operational requirements for providers

Documentation Required

Documentation-based review requirement

Documentation-based review may be required to determine whether scaling and root planing (periodontal therapy) meets the plan's medical/dental necessity and contractual coverage criteria. Submit the diagnostic and clinical documentation listed below when requested to support claims for D4341, D4342 and related procedures. The plan's determination that a service is medically or dentally necessary does not guarantee that it is a covered benefit under the member's contract.

Submit requested documentation promptly when pre-review or claim review is initiated.
The plan may deny or pend payment if required documentation is not provided.

Denial Risk

Insufficient documentation for multi‑quadrant procedures

When more than two quadrants of scaling and root planing are performed in a single appointment, the plan may request additional clinical and administrative documentation to support medical necessity. Failure to provide adequate documentation for multi‑quadrant procedures may result in claim denial or payment delay.

Additional documentation commonly requested for >2 quadrants: detailed quadrant‑level periodontal charting, tooth-level pocket depths, time spent per quadrant, and justification for multi‑quadrant treatment in one visit.
Claims for multi‑quadrant treatment may be audited; retain and submit complete records on request.

Documentation Required

Required diagnostic documentation

Required diagnostic records for review (must be labeled and dated, within 12 months of the procedure):

Full‑mouth radiographic series and/or a panoramic radiograph including bitewings.
6‑point periodontal charting (labeled and dated) with pocket depths recorded for each tooth.
Radiographs and periodontal charting should be included with the claim or submitted upon request for pre‑service or post‑service review.

Documentation Required

Adjunctive and clinical documentation

Adjunctive clinical documentation that should be provided to support the need for scaling and root planing includes objective measures of periodontal disease and treatment details.

Documentation of pocket depths (≥4 mm where treatment is claimed) and bleeding on probing.
Radiographic evidence of alveolar bone loss (vertical or horizontal) — bone level >1.5 mm apical to the CEJ supports periodontal bone loss.
Description of clinical inflammation and clinical findings, duration of the condition, and any prior nonsurgical therapy.
Record of local anesthesia administration (intramucosal injection) — topical or subgingival anesthetics alone do not qualify.
Time spent for scaling and root planing and post‑initial therapy evaluations/treatment planning notes may be requested for case review.

Note

Provider action: None specified

None specified.

Background on scaling and root planing

Scaling and root planing is a nonsurgical, therapeutic periodontal procedure performed to remove plaque, calculus, and diseased cementum from crown and root surfaces in order to treat periodontal pockets formed by migration of the epithelial attachment. The procedure is indicated for patients with periodontal pockets of at least 4 mm, documented bleeding on probing, and demonstrable radiographic bone loss (vertical or horizontal) with bone level > 1.5 mm apical to the CEJ. Local anesthesia must be administered by intramucosal injection for SRP; topical or subgingival anesthetic preparations do not meet the anesthesia requirement. Documentation supporting the procedure — including pocket depth measurements and radiographic evidence — is required for medical necessity review.

Definitions and qualifying diagnoses

Periodontal scaling and root planing — instrumentation

DefinitionInstrumentation of crown and root surfaces to remove plaque, calculus, and diseased cementum and dentin

Instrumentation typesPerformed using hand instruments and/or ultrasonic scalers

Procedure intentNonsurgical therapeutic procedure (not prophylactic) to treat periodontal pockets

AnesthesiaTypically performed with local anesthetic

Qualified diagnoses

Qualified diagnoses (payment eligible)Chronic periodontitis

Qualified diagnoses (payment eligible)Localized and generalized aggressive periodontitis

Qualified diagnoses (payment eligible)Localized and generalized periodontitis as a manifestation of systemic disease

Qualified diagnoses (payment eligible)Necrotizing periodontal diseases

Policy Summary

PayerEmpire Bluecross

PolicyScaling and Root Planing

Policy CodePolicy 04-301

Change TypeNo material change

Effective DateJan 1, 2022

Next Review Date

Key ActionSubmit full mouth or panoramic radiographs and labeled 6-point periodontal pocket charting dated within 12 months to support medical necessity review.

SourceLink

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