Medical Policy

Policy Num:     13.004.001
Policy Name:    Periodontal Surgical Services
Policy ID:          [13.004.001]  [Ac / L / M+ / P+]  [0.00.00]

Last Review:      October 24, 2024
Next Review:     October 20, 2025
 

Related Policies: None

Periodontal Surgical Services

Summary

The main objective of the periodontal surgical procedures is to be able to preserve the periodontal tissues for a long term. With scaling and root planning in conjunction with periodontal surgeries.

Objective

The purpose is to eliminate pockets and bone defects to restore an adequate morphology of the periodontium and be able to facilitate cleaning, controlling bacterial plaque.

Policy Statements

1.A history of a surgical code will limit for payment the approval of a second surgical code in a same

quadrant if three years have not passed.

2. Any surgical procedure for cosmetic purposes is excluded for payment.

3.  In those covers that do not include the benefit of implants, all procedures related to the implant are     excluded, such as, and not limited to, bone grafts and membranes in areas of extraction for implants and maintenance of dental implants.

4. Codes D4210 and D4211 are indicated for cases with gingival hyperplasia with none or minimal bone loss and are limited for payment to one of the two services per quadrant every 3 years.

5.  Code D4210 is used when the quadrant contains a minimum of 4 teeth that need surgery. Code D4211 will be used for cases in which it is only necessary to perform surgery in three teeth or less in the same quadrant.

6.  Every predetermination for soft tissue surgery requires a report indicating its necessity. You must include pictures, if they are available, as a diagnostic aid to advise in the case.

7.  The fee for codes D4240, D4241, D4260 and D4261 includes the fee of codes D4341 and D4342 when these are performed in the same quadrant, on the same day.

8.  Code D4245 is limited for payment to one per quadrant for life. A detailed "by report" is required and will not be considered for payment in conjunction with code D7960 if it is performed in the same visit. It will be billed using the quadrant number.

  9.  Code D4249 is limited to one payment per tooth per life and will be invoiced using the number of the tooth. The amount paid for codes D4249 in the same      quadrant may not exceed the rate of code D4260.

 10.  The rate of code D4249 was included in that of D4260 and D4261 if done in the set in the same affected area of the quadrant.

 11.  The following codes are limited to pay one per quadrant every three years: D4210, D4211, D4240, D4241, D4260, D4261, D4270, D4273 and these are        mutually exclusive. The quadrant number was used.

 12.  Codes D4263, D4264, D4277 and D4278 are made using the tooth number and will be limited to 1 per tooth per life. X-rays or photographs should be        sent to show the need and any other diagnostic help that may facilitate the evaluation of the case.

 13.  Codes D4277 and D4278 on the ADA sheet in the "observation" section should indicate the classification (MILLER).

 14.  The codes D4263 and D4264 must indicate the SITE of the bone defect in addition to the number of the tooth.

 15.  The codes D4266 and D4267 will be limited to 1 per quadrant every 3 years and is billed using the tooth number.

 16.  The codes D4277 and D4278 are mutually exclusive of codes D4270 and D4273.

 17.  The following codes will only be considered for payment in type II bifurcations and interproximal infrabony defects. (D4263, D4264, D4266 and D4267).

18.   Gingival grafts are limited for payment to one (1) per quadrant every three years and will be billed using the quadrant number.

Policy Guidelines

Every predetermination for soft tissue surgery requires a report indicating its necessity. You must include

pictures, if they are available, as a diagnostic aid to advice in the case.

Code D4245 is limited for payment to one per quadrant for life. A detailed " report" is required and will not be considered for payment in conjunction with code D7960 if it is performed in the same visit. It will be billed using the quadrant number.

 Codes D4277 and D4278 on the ADA sheet in the "observation" section should indicate the classification (MILLER). The codes D4263 and D4264 must indicate the SITE of the bone defect in addition to the number of the tooth.

Benefit Application

BlueCard/National Account Issues - N/A

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Definitions of interest:

Anatomical Crown: The portion of tooth normally covered by the enamel

Autogenous Graft: Tissue transferred from one position to another within the same individual.

Flap: A loosened section of tissue separated from the surrounding tissues except at it base.

Furcation: The anatomic area of a multirooted tooth where the root diverges.

Gingival Flap: A flap that does not extend apical to the mucogingival junction.

Gingivectomy: The excision or removal of gingiva

Gingivoplasty: Surgical procedure to reshape the gingiva

Miller Classification: Is the classification of Gingival Recession

Class I - Marginal tissue recession that does not extend to the mucogingival junction

Class II- Marginal tissue recession that extends to or beyond the mucogingival junction, with no periodontal attachment loss (bone or soft tissue) in the interdental area.

ClassIII- Marginal tissue recession that extends to or beyond the mucogingival junction, with periodontal attachment loss in the interdental area or malpositioning of teeth.

Class IV-Masrginal tissue recession that extends to or beyond the mucogingival junction, with severe bone or soft- tissue loss in the interdental area and/or or severe malpositioning of teeth.

Mobility: The movement of a tooth in its socket resulting from an applied force.

Osseous Surgery: Is the procedure to modify the bone that was affected by periodontal disease by reshaping the alveolar process to achieve physiologic form without affecting or removing alveolar supporting bone. In some cases, the removal of alveolar bone is needed to change the position of the crestal bone relative to the tooth root.

Quadrant: One of the four equal sections into wich the dental arches can be divided; begins in the midline of the arch and extends distally to the last tooth.

Recession: It is the location of marginal periodontal tissues apical to the cemento-enamel junction

Site: Describe a single area, or position. The word “site “is frequently used to indicate an area of soft tissue recession on a single tooth or an osseous defect adjacent to a single tooth; also used to indicate soft tissue defects and/or osseous defects in edentulous tooth positions.

Regulatory Status

N/A

Rationale

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American];LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflectiveof and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g.,women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Gingivectomy / Gingivoplasty is indicated for the following:

     1.  Elimination of suprabony pockets.

     2.  Elimination of gingival enlargement due to medications, medical conditions or tooth position.

     3.  Elimination of periodontal abscesses.

     4.  Exposure of soft tissue impacted tooth.

Anatomical crown exposure is indicated for the following in a periodontal healthy area:

    1. Facilitate the restoration of subgingival caries.

    2. Allow proper contour of restoration (Amalgam, resin or crown).

    3. Restore fracture tooth when the fracture extends subgingivally.

Bone replacement graft is indicated for the following:

    1. Infrabony vertical defects

    2. Clas II furcation involvements

Soft tissue grafting

Procedure consisting of free gingival grafts (autogenous or allografts) used to correct gingival recession.

There may be several causes for recession that includes mechanical factors (occlusion trauma, tooth brush abrasion), inflammatory factors (poor oral hygiene, periodontal desease) anatomical factors (minimavestibular depth, frenum involvement, thin periodontium, root prominence and position) and hereditary factors.

Population Reference No. 1 

Individual: with Suprabony pockets, Gingival enlargement, Impacted soft tissue teeth, Suprabony periodontal abcess.  Interventions of interest are: Periodontal surgical services (gingivectomy/gingivoplasty).  Comparators of interest are: Extractions Periodontal maintenance without surgery.  Relevant outcomes include: Quality of life, Healthy periodontium, Elimination of suprabony pockets, Elimination of gingival enlargement due to (medications, medical condition or tooth position), Elimination of suprabony periodontal abcess, Aid eruption on impacted teeths.

Population Reference No. 2 

Individual: With clinical crown length problems. Interventions of interest are: Periodontal surgical services (crown lengthening). Comparators of interest are: Extractions. Relevant outcomes include: Quality of life, Preservation of tooth, To allow restorative access.

Population Reference No. 3 

Individual: With vertical bone loss or class II furcation involvement. Interventions of interest are: Periodontal surgical services (Bone replacement graft).  Comparators of interest are: Periodontal treatment without grafts. Relevant outcomes include: Quality of life, Corrections of bone level or tissue problems.

Population Reference No. 4 

Individual: With Gingival recession. Interventions of interest are: Periodontal surgical services (soft tissue graft).  Comparators of interest are: Periodontal treatment without grafts, Tooth brushing education, Oral hygiene education, Occlusal adjustment in trauma cases.

Supplemental Information

N/A

Practice Guidelines and Position Statements

N/A

Medicare National Coverage

N/A

References

1.          Participating Periodontist Manual 2024, Periodontics / Rules and Limitations for Periodontics Surgical Services.

2.    Participating Odontologist Manual 2024, Periodontics / Rules and Limitations for Periodontics Surgical Services.

3.     Participating Odontopediatric Manual 2024, Periodontics / Rules and Limitations for  Periodontics Surgical Services.

4.     R. Matos Cruz, Antonio Bascones Martínez; avances en periodoncia e implantologia oral 1699- 6585 Vol 23 No3; 2011 pages 155-170. (Advances in periodontics and oral implantology 1699-6585 Vol 23 No 3 pages 155-170).

codes

Appplicable Modifiers

N/A

Policy History