Blue Cross Blue Shield FEP Dental Brochure - 2025
Blue Cross Blue Shield FEP Dental
Class B Intermediate
Class B Intermediate
Periodontal Services
D4341 Periodontal scaling and root planing - four or more teeth per quadrant - Limit 1 every 24 months, 2 quadrants per date of service
D4342 Periodontal scaling and root planing - one to three teeth per quadrant - Limit 1 every 24 months, 2 quadrants per date of service
D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation - Limit 3 in combination with D1110 Prophylaxis - adult and/or D1120 Prophylaxis - child during calendar year
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth - Service is covered for residual periodontal disease with inflammation and when necessary to treat specific sites that are unresponsive to prior active periodontal treatment
D4910 Periodontal maintenance - Limit 4 during the calendar year combined with adult prophylaxis, and scaling in presence of generalized moderate or severe gingival inflammation, after the completion of active periodontal therapy
D4342 Periodontal scaling and root planing - one to three teeth per quadrant - Limit 1 every 24 months, 2 quadrants per date of service
D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation - Limit 3 in combination with D1110 Prophylaxis - adult and/or D1120 Prophylaxis - child during calendar year
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth - Service is covered for residual periodontal disease with inflammation and when necessary to treat specific sites that are unresponsive to prior active periodontal treatment
D4910 Periodontal maintenance - Limit 4 during the calendar year combined with adult prophylaxis, and scaling in presence of generalized moderate or severe gingival inflammation, after the completion of active periodontal therapy
Class B Periodontal Services Notes:
Supporting documentation and criteria:
Non-surgical periodontal and periodontal maintenance procedures will be disallowed with no patient responsibility when submitted on the same date of service as preventive prophylaxis procedures.
Supporting documentation and criteria:
- Full mouth diagnostic quality radiographic images and/or a panoramic radiographic image including bitewings radiographs; labeled and dated (within 12 months of submitted procedure).
- Periodontal Charting: 6-point periodontal pocket depth charting as described by the ADA and American Academy of Periodontology (AAP) labeled and dated (within 12 months of submitted procedure).
- Teeth to be treated must demonstrate at least 4 millimeter (mm) pocket depths, bleeding on probing, with demonstrable radiographic evidence of bone loss (either vertical or horizontal) of the alveolar crest.
- Bone loss is considered to be a bone level that is greater 1.5 mm apical to the cementoenamel junction (CEJ).
Non-surgical periodontal and periodontal maintenance procedures will be disallowed with no patient responsibility when submitted on the same date of service as preventive prophylaxis procedures.