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Medical Policy                             

Policy Num:     13.004.002
Policy Name:    Periodontal non-Surgical Services
Policy ID:          [13.001.002]  [Ar / L / M+ / P+]  [0.00.00]

Last Review:     October 24, 2024
Next Review:     Policy Archived
 

Related Policies: None

Periodontal non-Surgical Services

Summary

Periodontal non- surgical services include all post-operative care. They are a range of therapeutic procedures to solve problems of gums and splinting of teeth.

Objective

To preserve the natural dentition /implants, gums and tissues to maintain and improve periodontal health, comfort and function. The healthy periodontium includes the absence of inflammatory of gums, swelling, suppuration and bleeding avoiding bone loss and future loss of tooth/ implants.

Policy Statements

All periodontal treatments need predetermination of benefits and the treatment plan for evaluation, should be submitted to Triple S Salud.

This allow both, the participant and the insured to confirm beforehand the eligibility of the service for the dental coverage, justification of services with supporting documents, the scope of the covered services, the limits, exclusions, to know which are the deductibles and coinsurance applicable under the insured’s contract.

Policy Guidelines

1. Code D4320 will be billed per tooth and this will be considered for payment one every three years per splinted tooth.

2. For code D4321 a "by report" must be submitted indicating the included teeth and the method used for splinting. The use of composite resins without reinforcement of wire mesh or its equivalent will not be accepted. Limited to one service per quadrant every 3 years.

3. The fee for codes D4341 and D4342 is included in the fee for D4240, D4241, D4260 and D4261 when these are performed in the same quadrant, on the same day.

4. Codes D4341 and D4342 will be considered for payment one service per quadrant every two years.

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 gingivitis;

        Is a common, non-contagious infection of the gum with sudden onset characterized with painful bleeding gums, and ulceration interdental papillae.

Gingival necession;

       Receding gums is the exposure in the roots of teeth caused by a loss of gum tissue and / or retraction of   the gingival, margin from the Crown of the teeth.

Periodontal scaling and root planning;

       The objective is to remove dental plaque and calculus wich house bacteria that release toxins wich cause inflammation to the gum tissue and         sorrounding bone.

Periodontitis;

       Is a serious gum infection that damage the soft tissue and destroys the bone that support your teeth.

 Splinting;

        Tying teeth together to increased stability to the entire unit of mobile teeth.

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.

Scaling and Root Planning is indicated for the following:

a- Localize or generalized mild to moderate chronic periodontal disease which implicate the loss of clinical attachment due to periodontal ligament destruction and loss of supporting bone.

b- Localize or generalize severe periodontal disease which implicates the loss of clinical attachment due to periodontal ligament destruction and loss of supporting bone.

On both Radiographic evidence of bone loss and tooth mobility are most likely seen Provisional Splinting using this code indicate the following:

a- Mobility of multiple teeth due to loss of alveolar bone loss and periodontium

b- Are used during the healing phases of regenerative periodontal therapy

Population Reference No. 1 

Individuals: With gums disease. Interventions of interest is: Periodontal non- surgical services (Scaling and Root Planning). Comparators of interest: Dental Prophylaxis, Periodontal maintenance Gingival irrigation per Quadrant. Relevant outcomes include: Better cleaning of teeth eliminating presence of supra and sub gingival tartar, To maintain healthy gums preventing other phases of gum disease needing surgical intervention.

Population Reference No. 2 

Individuals: With mobility of teeth. Intervention of interest is: Periodontal non- surgical services (Provisional Splinting). Comparators of interest: No treatment. Relevant outcomes include: Stabilization of teeth (Longer life of teeth avoiding extractions), Quality of life, Premature loss of teeth,Cost effective (avoiding needs of dentures (fixed or removable).

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 Non-Surgical Services.

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

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

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

  5.The American dental Association Council of scientific affairs (2015) 4 years study of non- surgical periodontal treatment with patients with chronic periodontitis via scaling and root planning with and/or without adjunctive services. The conclusion of the study revealed that patient treated with scaling and root planing resulted in greater improvement in clinical attachment levels compare to those only having prophylaxis, debridement and no treatment. Also the use of local antimicrobials/antibiotics help them to improve their periodontal condition.

  6. Azodo CC, Erhabor P. management of tooth mobility in the periodontology clinic; an overview and experience from a tertiary healthcare setting. AFR J MED HEALTH SCI 2016;15;50-7. The author explains the rational for splinting and all the attributes gaining to improve periodontics al health.

  7. Kathariya R, ET AL. to splint or not splint: the status of periodontal splinting. J INT ACAD Periodontal. 2016 APR 8;18(2):45-46

Codes

Appplicable Modifiers

N/A

Policy History