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Subject: Scaling in Presence of Generalized Moderate or Severe Gingival Inflammation
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).
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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.
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We consider CDT code D4346, “scaling in the presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation” to be a valid option for reporting services 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. Aetna defines “generalized” as representing greater than 50% percent of the mouth or remaining dentition.
We do not consider D4346 to be a valid option when there is a history of periodontal therapy performed in the past or concurrently with D4346.
CDT code D4346 was developed for inclusion in the CDT code set effective January 1, 2017. This procedure involves the treatment of patients with generalized moderate or severe gingival inflammation. CDT code D4346 filled a gap in the CDT code book between prophylaxis (D1110) and periodontal scaling and root planing (D4341/4342). This procedure is distinct from a prophylaxis, which is a preventive procedure. A prophylaxis is performed on patients with a generally healthy periodontium, where plaque and calculus are removed to control irritational factors, or on patients with localized gingivitis to prevent further progression of the disease. When more time than usual is required to remove plaque, calculus or excessive staining from the tooth structures, CDT code D1110 is still the appropriate code.
CDT code D4346 is not intended to describe a higher level of difficulty that is sometimes encountered when performing a prophylaxis. It is specifically used when reporting scaling in the presence of generalized (more than 50% percent of the mouth) moderate or severe gingival inflammation – full mouth, with or without pseudo-pockets but exhibiting no bone loss or loss of attachment.
Scaling and root planing is therapeutic in nature and is performed on patients who have bone loss and subsequent loss of attachment. Key to CDT code D4341/4342 is the instrumentation and removal of deposits from the root surfaces of the tooth.
Documentation to demonstrate the delivery of services to support the use of CDT code D4346 must consist of the following:
- Periodontal charting that records (pseudo) pocket depths and bleeding on probing. (Note: Clinical literature supports that pocket depths may be recorded without loss of attachment)
- Photographs or other diagnostic images, such as radiographic images to document the presenting condition of the patient. These items would also help to document whether the patient’s condition is localized versus generalized in greater than 50% percent of the mouth.
The above documentation should be retained in the patient’s dental record and provided to Aetna upon request to support the procedure performed.
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 presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation.
See Dental Clinical Policy Bulletin 041 – Scaling and root planing
Original policy: July 19, 2016
Updated: November 13, 2017; February 19, 2019; April 2, 2020; August 11, 2021, July 11, 2022
The above policy is based on the following references:
American Dental Association. CDT 2022. Dental Procedure Codes.
Copyright 2022 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.
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