Blue Cross Blue Shield FEP Dental
Class B Intermediate
Class B Intermediate
Periodontal Services
D4341 Periodontal scaling and root planing - four or more teeth per quadrant - Limit 1 every 24 months, 2 quadrants per date of service
D4342 Periodontal scaling and root planing - one to three teeth per quadrant - Limit 1 every 24 months, 2 quadrants per date of service
D4346 Scaling in presence of generalized moderate or severe gingival inflammation - Full mouth, after oral exam - Limited 3 in combination with D1110 and/or D1120 during calendar year
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
D4910 Periodontal maintenance - Limit 4 every12 months combined with adult prophylaxis, and scaling in presence of generalized moderate or severe gingival inflammation, after the completion of active periodontal therapy
D4342 Periodontal scaling and root planing - one to three teeth per quadrant - Limit 1 every 24 months, 2 quadrants per date of service
D4346 Scaling in presence of generalized moderate or severe gingival inflammation - Full mouth, after oral exam - Limited 3 in combination with D1110 and/or D1120 during calendar year
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
D4910 Periodontal maintenance - Limit 4 every12 months combined with adult prophylaxis, and scaling in presence of generalized moderate or severe gingival inflammation, after the completion of active periodontal therapy
Class B Periodontal Services Notes:
Supporting documentation and criteria;
Non-surgical periodontal and periodontal maintenance procedures will be disallowed with no patient responsibility when submitted on the same date of service as preventive prophylaxis procedures.
Supporting documentation and criteria;
- Full mouth diagnostic quality radiographic images and/or a panoramic radiographic image including bitewings radiographs; labeled and dated (within 12 months of submitted procedure).
- Periodontal Charting: 6-point periodontal pocket depth charting as described by the ADA and American Academy of Periodontology (AAP) labeled and dated (within 12 months of submitted procedure).
- Teeth to be treated must demonstrate at least 4 millimeter (mm) pocket depths, bleeding on probing, with demonstrable radiographic evidence of bone loss (either vertical or horizontal) of the alveolar crest.
- Bone loss is considered to be a bone level that is greater 1.5 mm apical to the cementoenamel junction (CEJ).
Non-surgical periodontal and periodontal maintenance procedures will be disallowed with no patient responsibility when submitted on the same date of service as preventive prophylaxis procedures.