Periodontics Section - Full Mouth Debridement
|Topic: Full Mouth
||Date of Origin: January 2011
||Policy No: 36K
|Last Reviewed: January 2015
|Approved: January 2015
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.
Full mouth debridement to enable comprehensive
evaluation and diagnosis (D4355):
The removal of subgingival and/or supragingival plaque
and calculus. This procedure does not preclude the
need for other procedures.
Procedures are in accordance with generally
accepted standards of dental practice.
- Debridement allowed once every three years (provided D1110, D4910, D4341, have not been done within the last three years).
- Debridement is not a substitute for difficult prophylaxis.
- Considered inclusive if billed on same day as D1110, D4910 or D4341.
Process to contract benefits.
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