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Scaling in Presence of Generalized Moderate or Severe Gingival Inflammation (042)

Number: 042
(Updated)

Subject: Scaling in Presence of Generalized Moderate or Severe Gingival Inflammation

Reviewed: July 19, 2016

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 CDT code D43461,  “scaling in the presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation”1 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. 

Background

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)2 and periodontal scaling and root planing (D4341/4342)2. 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:

1. 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)

2. 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.

Codes1,2

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

See Dental Clinical Policy Bulletin 041 – Scaling and root planing

Revision Dates

Original policy: July 19, 2016
Updated: 
Revised: 

The above policy is based on the following references:

1American Dental Association. CDT 2016. Dental Procedure Codes: 15,36-37.*

2American Dental Association. CDT 2017. Dental Procedure Codes:15,39**

*Copyright 2015 American Dental Association.  All rights reserved.

**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.

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Clinical Policy Bulletins

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  • Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.
  • While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. 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. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits 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 or the Federal government.
  • Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.
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  • Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.
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