Periodontics Section - Gingival Flap Procedure,
Including Root Planing
| Topic: Gingival Flap
Procedure, Including Root Planing |
Last Reviewed Date:
01/2003 |
| Section: Periodontics |
Policy No: 32 |
| Revised/Effective Date: 01/2003
|
Next Review Date: 01/2004 |
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
Gingival flap procedure, including root planing
– per quadrant (D4240):
Surgical debridement of the root surface and the
removal of granulation tissue following the resection
or reflection of soft tissue flap. Osseous recontouring
is not accomplished in conjunction with this procedure.
May include open flap curettage, reverse bevel flap
surgery, modified Kirkland flap procedure. Widman
surgery, and modified Widman surgery. This procedure
is performed in the presence of moderate to deep probing
depths, loss of probing attachment, need to maintain
esthetics, and need for increased access to the root
surface and alveolar bone.
Gingival flap procedure, including root planing- one
to three teeth, per quadrant (D4241):
Policy/Criteria
Procedures are in accordance with generally
accepted standards of dental practice.
Gingival flap procedure is considered a primary procedure
and may be associated with secondary procedures such
as bone replacement grafts (D4263, D4264) or guided
tissue regeneration (D4267, D4268). An appropriate pro-rated
fee is administered for D4240 per teeth involved and
qualifying secondary procedure benefits are provided.
Procedure is subject to review and requires documentation
for determination of benefit estimate or claims payments
including:
- Current periodontal charting and radiographs of
the area involved
- A narrative is required
- Less than 4 teeth per quadrant (D4241) is considered
at 50% benefit of D4240
Administrative Guidelines
Process to contract benefits.
| Codes |
Number |
Description |
| CDT |
D4000-D4999 |
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