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Subject: Full-Mouth Debridement to Enable Comprehensive Periodontal Evaluation and Diagnosis on a Subsequent Visit
Reviewed: July 11, 2022
This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in this Bulletin. The discussion, analysis, conclusions and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna’s opinion and are made without any intent to defame.
Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.
The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (for example, will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. CMS's Coverage Database can be found on the following website:
Visit the CMS coverage database
This procedure may be considered for coverage under certain dental plans. Treatment must be determined to be necessary, appropriate and consistent with the guidelines established by the American Academy of Periodontology (AAP) and the American Dental Association (ADA).
The AAP defines active therapy as “surgical and/or nonsurgical periodontal therapies exclusive of full-mouth debridement.” Full-mouth debridement is intended for patients with excessive plaque and calculus that interferes with the ability of the dental professional to perform a comprehensive periodontal evaluation. Full-mouth debridement is considered a preliminary, non-therapeutic procedure. It is indicated in rare situations when the patient has not had a dental visit for a prolonged period of time.
D4355 - Full-mouth debridement to enable comprehensive periodontal evaluation and diagnosis on a subsequent visit
Original policy: April 12, 2005
Updated: March 15, 2006; May 24, 2010; April 25, 2011; May 21, 2012; August 12, 2013; June 9, 2014; June 22, 2015; May 23, 2016; May 21, 2018; April 2, 2020; August 11, 2021; July 11, 2022
Revised: March 12, 2007; April 29, 2008; March 30, 2009
The above policy is based on the following references:
American Dental Association. CDT 2023 Dental Procedure Codes.
American Academy of Periodontology. Comprehensive periodontal therapy: a statement by the American Academy of Periodontology. Journal of Periodontology. 2011 July;82(7):943-949. Accessed July 11, 2022.
Copyright 2023 American Dental Association. All rights reserved.
Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and, therefore, is subject to change.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
Health benefits and health insurance plans contain exclusions and limitations.