Number: 041
(Updated)

Subject: Scaling and Root Planing

Reviewed: November 13, 2017

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 benefits 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 benefits plan to determine if there are any exclusions or other benefits 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. 

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Policy

We consider scaling and root planing to be a procedure that involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical therapy in others.

Background

According o the American Academy of Periodontology treatment guidelines, periodontal health should be achieved in the least invasive and most cost-effective manner. This is often accomplished through non-surgical periodontal treatment.  Scaling and root planing is the primary non-surgical treatment modality.

After scaling and root planing, many patients do not require further active treatment. However, surgery may be indicated to restore periodontal health when scaling and root planing is not effective.

Periodontal scaling and root planing (D4341/4342)¹ is distinctly different from a dental prophylaxis (D1110)¹ and scaling in the presence of generalized moderate or severe gingival inflammation (D4346, effective January 1, 2017).² Prophylaxis is a preventive procedure and is performed on patients with a generally healthy periodontium, or on patients with localized gingivitis. Scaling in the presence of generalized moderate or severe gingival inflammation is indicated for patients who have generalized moderate to severe gingival inflammation, with or without pseudo-pockets but exhibiting no bone loss or loss of attachment. Key to scaling and root planing is the instrumentation and removal of deposits from the root surfaces of the tooth.  

The following documentation is needed to support the delivery of scaling and root planing:

1. Periodontal charting that records pocket depths, including 6 points per tooth, and bleeding on probing.

2. Full-mouth radiographs or digital images

The diagnostic materials must demonstrate the following:

• Clinical loss of periodontal attachment 

• Radiographic evidence of crestal bone loss or changes in crestal lamina dura 

• Radiographic evidence of root surface calculus

The above documentation should be retained in the patient’s dental record and provided to Aetna upon request to support the procedure performed.

Codes^1,2

D1110 – prophylaxis – adult

D4341– periodontal scaling and root planing – four or more teeth per quadrant

D4342 – periodontal scaling and root planing – one to three teeth per quadrant

D4346 – scaling in the presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation. Effective January 1, 2017

See Dental Clinical Policy Bulletin 042 – Scaling in Presence of Generalized Moderate or Severe Gingival Inflammation

Revision Dates

Original policy: July 19, 2016
Updated: November 13, 2017
Revised: 

The above policy is based on the following references:

¹American Dental Association. CDT 2017. Dental Procedure Codes.*

²Smiley, CJ. et al. Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. The Journal of the American Dental Association, Volume 146, Issue 7, 525 – 535.

³American Academy of Periodontology. Parameter on chronic periodontitis with slight to moderate loss of periodontal support. J Periodontol 2000;71:853-855.

⁴Lang NP, Tonetti MS.  Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral Health & Preventive Dentistry 1/2003, S. 7-16. Accessed July 18, 2016. Available at: http://www.perio-tools.com/pdf/Lang_&_Tonetti_2003.pdf

*Copyright 2016 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.