Skip to main content

Initial periodontal therapy reevaluation (040)

Number: 040


Subject: Initial Periodontal Therapy Reevaluation


Reviewed: March 20, 2023


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. 


Visit the CMS coverage database




We consider an interval of at least six weeks an appropriate and ideal time to reevaluate following periodontal scaling and root planing (CDT D4341/D4342). Reevaluation assesses the patient’s initial tissue response, before considering additional periodontal therapy. The reevaluation should be documented and include metrics such as periodontal pocket recordings.




The primary function of reevaluation is to determine the effectiveness of scaling and root planing and to review the proficiency of home care.


The initial therapy’s outcome should be reevaluted after an appropriate interval for resolution of inflammation and tissue repair. A periodontal examination and re-evaluation may be performed with the relevant clinical findings documented in the patient’s record. These findings may be compared to initial documentation to assist in determining the outcome of initial therapy as well as the need for and the type of further treatment.


According to the American Academy of Periodontology and European Federation of Periodontology, depending on the treatment performed, patient reevaluation should occur at six weeks to three months post-therapy.  The consensus report from the most recent American Academy of Periodontology World Workshop indicates that a six-week interval is usually adequate to assess the initial response to therapy.




D0140 – Limited oral evaluation – problem focused
D0170 – Re-evaluation – limited, problem focused (established patient; not post-operative)
D0180 – Comprehensive periodontal evaluation – new or established patient
D4341 – Periodontal scaling and root planing – four or more teeth per quadrant
D4342 – Periodontal scaling and root planing – one to three teeth per quadrant


Revision dates


Original policy: March 17, 2015


Update: April 28, 2016; April 27, 2017; April 26, 2018; April 29, 2019; May 13, 2020; October 28, 2021

Revised: March 20, 2023


The above policy is based on the following references:


Decisions in Dentistry. July 2022;8(7)26-29.


American Dental Association. CDT 2023 Dental Procedure Codes.


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.

Legal notices

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.

Also of interest: