Number: 012
Revised

Subject: Periodontal Pocket Reduction Surgery

Date: September 8, 2020

Important note

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: http://www.cms.hhs.gov/center/coverage.asp.

Policy

We consider these surgical procedures to be dental-in-nature (DIN) oral surgery. Coverage may be available for DIN oral surgery procedures under either medical or dental plans.

Background

Periodontitis presents as microbially‐associated, host‐mediated inflammation that results in loss of periodontal attachment.  Alveolar bone loss is a key secondary feature of periodontitis.

To prevent progression of the disease, initial treatment is directed toward:

• Improving home care
• Reducing plaque/biofilm
• Treating of local factors such as defective restorations
• Reviewing systemic health, including consultation with medical providers to modify medications and /or dental treatment as necessary
• Removing associated calculus buildup (scaling and root planing to remove plaque and calculus from periodontal pockets and to smooth the tooth roots to remove bacterial toxins) 

When scaling and root planing of the teeth cannot halt progression of the disease, it may be necessary to address these defects surgically. This can be accomplished via gingival flap surgery, osseous surgery or gingivectomy.

Gingival flap surgery is a procedure that is performed by reflecting a soft tissue flap; in the presence of moderate to deep probing depths, loss of attachment, need for increased access to the root surface and alveolar bone, or to determine the presence of hidden tooth defects. If root planing is needed, it is by definition considered to be part of the gingival flap surgery. Osseous recontouring is not accomplished in conjunction with this procedure.

Osseous surgery is a dentoalveolar surgical procedure that may be necessary for isolated defects of supporting bone or for more generalized bony defects that involve an entire quadrant. A quadrant is defined as one of the four equal sections into which the dental arches can be divided. It begins at the midline of the arch and extends distally to the last tooth.

Osseous surgery requires development of a full mucoperiosteal flap reflection of the gingiva (gums), underlying connective tissue and periosteum for access to the osseous defects and root surfaces of teeth. The procedure modifies the bony support of the teeth by reshaping the alveolar process to achieve a more physiologic form. This must include the removal of supporting bone (ostectomy) and/or non-supporting bone (osteoplasty).¹

Osseous surgery is one of the most common periodontal procedures performed for surgical correction of osseous defects.

Gingivectomy is a pocket reduction surgery that is performed to eliminate suprabony pockets and/or create a hygienic gingival contour.  

The necessity of these surgical procedures will be determined by a detailed clinical examination, dental history review, medical history review, oral hygiene review, necessary diagnostic tests, consultations with other health care professionals, and diagnostic procedures such as radiographs and periodontal charting. 

Coverage is only available in dental plans that cover these specific periodontal services.  In those plans, the available benefit is limited to a total of one type of pocket reduction surgery per quadrant or tooth, in any 36 consecutive months. 

Since osseous surgery requires a full mucoperiosteal flap and bone removal, the LANAP procedure is not considered osseous surgery. When it meets established clinical guidelines for necessity, LANAP will be benefited at the level of scaling and root planing, D4341/D4342, Periodontal Scaling and Root Planing.¹

Refer to CPB #13 -- Bone Replacement Grafts.

Codes¹

D4210 - Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant

D4211 - Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant

D4240 - Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant

D4241 - Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant

D4260 - Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant

D4261 - Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant

Revision Dates

Original: November 22, 2005
Updated: November 28, 2007; December 29, 2008; December 21, 2009; February 28, 2011; December 4, 2012; January 13, 2014; January 26, 2015; February 17, 2016; May 21, 2018; November 7, 2018; September 8, 2020
Revised: November 20, 2006; August 28, 2019

The above policy is based on the following references:

¹American Dental Association. CDT 2020 Dental Procedure Codes.*

²American Academy of Periodontology. Parameter on chronic periodontitis with slight to moderate loss of periodontal support. J Periodontal. 2000; 71:853-855.

³American Academy of Periodontology. Parameter on chronic periodontitis with advanced loss of periodontal support. J Periodontal. 2000; 71:856-858.

⁴American Academy of Periodontology. Parameter on comprehensive periodontal examination. J Periodontal. 2000; 71:847-848.

*Copyright 2019 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.