Periodontics Section - Gingivectomy or Gingivoplasty

IMPORTANT INFORMATION This Dental Policy has been developed through consideration of generally accepted standards of dental practice, review of dental literature, dental necessity, and as appropriate, government approval. Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. The purpose of dental policy is to provide a guide to coverage. Dental policy is not intended to dictate to providers how to practice dentistry. Providers are expected to exercise their clinical judgment in providing the most appropriate care.

Description
Gingivectomy or Gingivoplasty – four or more contiguous teeth or bounded teeth spaces per quadrant (D4210):

Involves the excision of the soft tissue wall of the periodontal pocket by either an external or an internal bevel. Performed in shallow to moderate suprabony pockets after adequate initial preparation, for suprabony pockets which need access for restorative dentistry, when moderate gingival enlargements or aberrations are present and when there is asymmetrical or unesthetic gingival topography.

Gingivectomy or Gingivoplasty – one to three teeth, per quadrant (D4211): See D4210.

Policy/Criteria
Procedures are in accordance with generally accepted standards of dental practice.

Procedure is subject to review with periodontal charting and narrative.

1. When moderate gingival pocket depths or topographical aberrations are present inhibiting good oral health.
2. To facilitate restorative dentistry.
3. Cosmetic exclusion applies unless tissue alterations are due to effects of medications.

Administrative Guidelines
Process to contract benefits.

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