2020
Clinical Criteria, Guidelines
and Practice Parameters
CLINICAL DENTISTRY GUIDELINES
Clinical Criteria Guidelines
Page 2
PREFACE
LIBERTY Dental Plan’s Clinical Criteria Guidelines and Practice Parameters were originally developed in 2005 and are
subject to periodic revisions and annual review by the QMI Committee and Board of Directors. The criteria document
was developed internally by our Dental Directors with input from participating panel general dentists and specialists.
LIBERTY utilizes the American Dental Association’s “Dental Practice Parameters,” sound dental clinical principles,
processes and evidence to consistently evaluate the appropriateness of dental services that require review.
LIBERTY Dental Plan Executive Approval
The LIBERTY Dental Plan Quality Management and Improvement Committee has reviewed and approved the Clinical
Criteria, Guidelines and Practice Parameters.
________________ 12-04-2019___
Dr. Peter Fuentes /National Dental Director Date
LIBERTY Dental Plan’s Board of Directors has reviewed and approved the Clinical Criteria, Guidelines and Practice
Parameters as proposed by the Quality Management Committee.
12-19-2019
Executive Vice President/Board Representative Date
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Clinical Criteria Guidelines
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Please note that specific Plan/Program guidelines supersede the information contained in LIBERTY’s Clinical Criteria
Guidelines and Practice Parameters document.
TABLE OF CONTENTS
NEW PATIENT INFORMATION ................................................................................................................................................. 4
CLINICAL ORAL EVALUATIONS ................................................................................................................................................ 4
INFORMED CONSENT ……………………………………………………………………………………………………………………………………………………… 5
PRE-DIAGNOSTIC SERVICES ..................................................................................................................................................... 5
DIAGNOSTIC IMAGING ............................................................................................................................................................ 5
TESTS, EXAMINATIONS AND REPORTS .................................................................................................................................... 6
PREVENTIVE TREATMENT ....................................................................................................................................................... 6
RESTORATIVE TREATMENT ..................................................................................................................................................... 7
ENDODONTICS ........................................................................................................................................................................ 9
PERIODONTICS ...................................................................................................................................................................... 11
REMOVABLE PROSTHETICS ................................................................................................................................................... 16
ORAL SURGERY ...................................................................................................................................................................... 18
ADJUNCTIVE SERVICES .......................................................................................................................................................... 19
RETROSPECTIVE REVIEW ....................................................................................................................................................... 22
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Clinical Criteria Guidelines
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NEW PATIENT INFORMATION
A. Registration information should include:
1. Name, sex, birth date, address and telephone number, cell phone number, e-mail address, name of employer,
work address and telephone number, language of preference.
2. Name and telephone number of person(s) to contact in an emergency.
3. For minors, name of parent(s) or guardian(s) and telephone numbers, if different from above.
4. Pertinent information relative to the patient’s chief complaint and dental history, including any problems or
complications with previous dental treatment, previous dentist/dental clinic and date of last dental examination.
5. Medical History - There should be a detailed medical history form comprised of questions which require a Yes
or “No” response, including:
a. Patient’s current health status
b. Name and telephone number of physician and date of last visit
c. History of hospitalizations and/or surgeries
d. Current medications, including dosages and indications
e. History of drug and medication use (including Fen-Phen/Redux and bisphosphonates)
f. Allergies and sensitivity to medications (including antibiotics) or materials (including latex)
g. Adverse reaction to local anesthetics
h. History of diseases or conditions:
i. Cardio-vascular disease, including history of abnormal (high or low) blood pressure, heart attack,
stroke, history of rheumatic fever or heart murmur, existence of pacemakers, valve replacements
and/or stents and bleeding problems, etc.
ii. Pulmonary disorders including COPD, tuberculosis, asthma and emphysema
iii. Nervous disorders, including psychiatric treatment
iv. Diabetes, endocrine disorders, and thyroid abnormalities
v. Liver or kidney disease, including hepatitis and kidney dialysis
vi. Sexually transmitted diseases
vii. Disorders of the immune system, including HIV status/AIDS
viii. Other viral diseases
ix. Musculoskeletal system, including prosthetic joints and when they were placed
x. History of cancer, including radiation or chemotherapy
6. Pregnancy
a. Document the name of the patient’s obstetrician and estimated due date.
b. Follow current guidelines in the ADA publication, Women’s Oral Health Issues.
7. The medical history form must be signed and dated by the patient or patient’s parent or guardian.
8. Dentist’s notes following up patient comments, significant medical issues and/or consultation with a physician
should be documented on the medical history form or in the progress notes.
9. Medical alerts for significant medical conditions must be uniform and conspicuously located on the monitor for
paperless records or on a portion of the chart used and visible during treatment and should reflect current
conditions.
10. The dentist must sign and date all baseline medical histories after review with the patient. If electronic dental
records are used, indication in the progress notes that the medical history was reviewed is acceptable.
11. The medical history should be updated at appropriate intervals, dictated by the patient’s history and risk factors,
and must be documented at least annually and signed by the patient and dentist.
CLINICAL ORAL EVALUATIONS
A. Periodic oral evaluations (Code D0120) of an established patient may only be provided for a patient of record who
has had a prior comprehensive examination. Periodontal evaluations and oral cancer screenings should be updated
at appropriate intervals, dictated by the patient’s history and risk factors, and should be done at least annually.
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B. A problem-focused limited examination (Code D0140) must document the issue substantiating the medical necessity
of the examination and treatment. (MM014)
C. An oral evaluation of a patient less than seven years of age should include documentation of the oral and physical
health history, evaluation of caries susceptibility and development of an oral health regimen.
D. A comprehensive oral evaluation for new or established patients (Code D0150) who have been absent from active
treatment for at least three years or have had a significant change in health conditions should include the following:
1. Observations of the initial evaluation are to be recorded in writing and charted graphically where appropriate,
including missing or impacted teeth, existing restorations, prior endodontic treatment, fixed and removable
appliances.
2. Assessment of TMJ status (necessary for adults) and/or classification of occlusion (necessary for minors) should
be documented.
3. Full mouth periodontal screening must be documented for all patients; for those patients with an indication of
periodontal disease, probing and diagnosis must be documented, including a radiographic evaluation of bone
levels, gingival recession, inflammation, etiologic factors (e.g., plaque and calculus), mobility, and furcation
involvements.
4. A soft tissue/oral cancer examination of the lips, cheeks, tongue, gingiva, oral mucosal membranes, pharynx and
floor of the mouth must be documented for all patients, regardless of age.
E. A post-operative office visit for re-evaluation should document the patient’s response to the prior treatment.
(MM014)
INFORMED CONSENT
A. The dentist should have the member sign appropriate informed consent documents and financial agreements.
B. Following an appropriate informed consent process, if a patient elects to proceed with a procedure that is not
covered, the member is responsible for the dentist’s usual fee.
PRE-DIAGNOSTIC SERVICES
A. Screening of a patient, which includes a state or federal mandate, is used to determine the patient’s need to see a
dentist for diagnosis.
B. Assessment of a patient is performed to identify signs of oral or systemic disease, malformation or injury and the
potential need for diagnosis and treatment.
DIAGNOSTIC IMAGING
Based on the dentist’s determination that there is generalized oral disease or a history of extensive dental treatment, an
adequate number of images should be taken to make an appropriate diagnosis and treatment plan, per current
FDA/ADA radiographic guidelines to minimize the patient's exposure. Photographic images may also be needed to
evaluate and/or document the existence of pathology.
A. An attempt should be made to obtain any recent radiographic images from the previous dentist.
B. An adequate number of initial radiographic images should be taken to make an appropriate diagnosis and treatment
plan, per current FDA/ADA radiographic guidelines. This includes the ALARA Principle (As Low as Reasonably
Achievable) to minimize the patient’s exposure. It is important to limit the number of radiographic images obtained
to the minimum necessary to obtain essential diagnostic information. (MM020)
C. The patient should be evaluated by the dentist to determine the radiographic images necessary for the examination
prior to any radiographic survey.
D. Intraoral complete series (including bitewings) (Code D0210)
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Note: D0210 is a radiographic survey of the whole mouth, usually consisting of 14-22 periapical and posterior bitewing
images intended to display the crowns and roots of all teeth, periapical areas and alveolar bone.
1. Benefits for this procedure are determined within each plan design.
2. Any benefits for periapical and/or bitewing radiographs taken on the same date of service will be limited to a
maximum reimbursement of the provider’s fee for a complete series.
3. Any panoramic film taken in conjunction with periapical and/or bitewing radiograph(s) will be considered as a
complete series, for benefit purposes only.
4. Decisions about the types of recall films should also be made by the dentist and based on current FDA/ADA
radiographic guidelines, including the complexity of previous and proposed care, caries, periodontal
susceptibility, types of procedures and time since the patient’s last radiographic examination.
E. Diagnostic radiographs should reveal contact areas without cone cuts or overlapping, and periapical films should
reveal periapical areas and alveolar bone.
F. Radiographs should exhibit good contrast.
G. Diagnostic digital radiographs should be submitted electronically when possible or should be printed on
photographic quality paper and exhibit good clarity and brightness.
H. All radiographs must be mounted, labeled left/right and dated.
I. Intra or extra-oral photographic images should only be taken to diagnose a condition or demonstrate a need for
treatment that is not adequately visualized radiographically. (MM0350)
J. Any patient refusal of radiographs should be documented.
K. Radiograph duplication fees:
1. Radiographic image duplication fees are not allowed.
2. When a patient is transferred from one contracted provider to another, diagnostic copies of all radiographic
images less than two years old should be duplicated for the second provider.
L. Diagnostic casts (Code D0470) are only considered medically necessary as an aid for treatment planning specific oral
conditions. (MM047)
TESTS, EXAMINATIONS AND REPORTS
A. Tests, examinations and reports may be required when medically necessary to determine a diagnosis or treatment
plan for an existing or suspected oral condition or pathology. (MM041, MM047)
B. Oral pathology laboratory procedure/report may be required when there is evidence of a possible oral pathology
problem. (MM0472).
PREVENTIVE TREATMENT
A. Dental prophylaxis (Code D1110 and D1120) may be medically necessary when documentation shows that there is
evidence of plaque, calculus or stains on tooth structures. (MM111)
B. Topical fluoride (Codes D1206 and D1208) treatment may be medically necessary when documentation shows that
there is evidence of the need for this preventive procedure. (MM120)
C. A sealant (Code D1351) or preventive resin restoration (Code D1352) may be medically necessary to prevent decay
in a pit or fissure or as a conservative restoration in a cavitated lesion that has not extended into dentin on a
permanent tooth in a moderate to high caries risk patient. (MM135)
D. A space maintainer (Codes D1510D1525) may be medically necessary to prevent tooth movement and/or
facilitate the future eruption of a permanent tooth. (MM150)
E. Recognizing medical conditions that may contribute to or precipitate the need for additional prophylaxis
procedures, supported by the patient’s physician. Verify plan benefits prior to performing additional prophylaxis
procedures in excess of plan limitations.
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F. Interim caries arresting medicament application (Code D1354) Silver Diamine Fluoride (SDF) is an interim caries
arresting liquid medicament clinically applied to control and prevent the further progression of active dental caries
and reduce dental hypersensitivity. Treatment with Silver Diamine Fluoride will not eliminate the need for
restorative dentistry to repair function or aesthetics, but this alternative treatment allows oral health care
professionals to temporarily arrest caries with noninvasive methods, particularly with young children that have
primary teeth. This should be submitted on a per tooth basis.
RESTORATIVE TREATMENT
A. Restorative procedures for teeth exhibiting a poor prognosis due to gross carious destruction of the clinical crown
at/or below the bone level, advanced periodontal disease, untreated periapical pathology or poor restorability are
not covered. (MMPROG_) (MMPROGR)
B. Amalgam Restorations (Codes D2140-D2161)
1. Dental amalgam is a cavity-filling material made by combining mercury with other metals such as silver, copper
and tin. Numerous scientific studies conducted over the past several decades, including two large clinical trials
published in the April 2006 Journal of the American Medical Association, indicate dental amalgam is a safe,
effective cavity-filling material for children and others. And, in its 2009 review of the scientific literature on
amalgam safety, the ADA's Council on Scientific Affairs reaffirmed that the scientific evidence continues to
support amalgam as a valuable, viable and safe choice for dental patients…”
2. On July 28, 2009, the American Dental Association (ADA) agreed with the U.S. Food and Drug Administration's
(FDA) decision not to place any restriction on the use of dental amalgam, a commonly used cavity filling
material:
a. The procedures of choice for treating caries or the replacement of an existing restoration not involving or
undermining the cusps of posterior teeth is generally amalgam or composite.
b. Facial or buccal restorations are generally considered to be “one surface” restorations, not three surfaces
such as MFD or MBD. (MMMOD)
c. The replacement of clinically acceptable amalgam fillings with an alternative material (composite, crown,
etc.) is considered cosmetic and is not covered unless decay or fracture of the existing filling is present.
(MMTRT)
d. If a dentist chooses not to provide amalgam fillings, alternative posterior fillings must be made available for
LIBERTY patients. Any listed amalgam copayments would still apply.
e. An amalgam restoration includes tooth preparation and all adhesives, liners and bases. (MMINC)
f. An amalgam restoration may be medically necessary when a tooth has a fracture, defective filling or decay
penetrating into the dentin. (MM214)
g. An amalgam restoration should have sound margins, appropriate occlusion and contacts and must treat all
decay that is evident. (MM241)
C. Resin-based Composite Restorations (Codes D2330 D2394)
1. The procedures of choice for treating caries or the replacement of an existing restoration not involving or
undermining the incisal edges of an anterior tooth is composite. Decay limited to the incisal edge only, may still
be a candidate for a filling restoration if little to no other surfaces manifest caries or breakdown.
2. Facial or buccal restorations are generally considered to be “one surface” restorations, not three surfaces such
as MFD or MBD. (MMMOD)
3. The replacement of clinically acceptable amalgam fillings with alternative materials (composite, crown, etc.) is
considered cosmetic and is not covered unless decay or fracture is present. (MMTRT)
4. A resin-based composite restoration includes tooth preparation, acid etching, adhesives, liners, bases and
curing. (MMINC)
5. A resin-based composite restoration may be medically necessary when a tooth has a fracture, defective filling,
recurrent decay or decay penetrating into the dentin. (MM230) (MM231)
6. A composite restoration should have sound margins, appropriate occlusion and contacts and must treat all
decay that is evident. (MM232)
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7. If LIBERTY determines that there is a more appropriate procedure code to describe the restoration provided,
either number of surfaces, or material used, an alternate procedure code may be approved. (MM230M)
(MM232M) (MM240M) (MM241M)
D. Restorations for primary teeth are covered only if the tooth is symptomatic, proximal to permanent teeth, or
expected to be present for six months or longer. (MM290)
E. For posterior primary teeth that have had extensive loss of tooth structure or when it is necessary for preventive
reasons, the appropriate treatment is generally a prefabricated stainless steel crown or for anterior teeth, a stainless
steel or prefabricated resin crown.
F. A resin infiltration of an incipient smooth surface lesion (decalcification) is appropriate for smooth surface lesions
with some or minor enameloplasty. (MM2990)
G. Crowns - Single Restorations Only (Codes D2712D2791)
1. Administrative Issues
a. Providers may document the date of service for these procedures to be the date when final impressions are
completed (subject to review).
b. Providers must complete any irreversible procedure started regardless of payment or coverage and only bill
for indirect restorations when the service is completed (permanently cemented).
c. Crown services must be documented using valid procedure codes in the American Dental Association’s
Current Dental Terminology (CDT).
2. A crown may be medically necessary when the tooth is present and:
a. The tooth has evidence of decay undermining more than 50% of the tooth (making the tooth weak), when a
significant fracture is identified, or when a significant portion of the tooth has broken or is missing and has
good endodontic, periodontal and/or restorative prognoses (MM272) (MM273) (MM237R) (MM274)
(MM274E) (MM275) (MM275P) and is not required due to wear from attrition, abrasion and/or erosion
(MM2LIM).
b. There is a significantly defective crown (defective margins or marginal decay) or there is recurrent decay.
(MM270)
c. The tooth is in functional occlusion. (MM271)
d. When anterior teeth have incisal edges/corners that are undermined or missing because of caries, a
defective restoration or are fractured off, a labial veneer may not be sufficient. The treatment of choice may
be a porcelain fused to base metal crown or a porcelain/ceramic substrate crown. (MM296)
e. The tooth has a good endodontic, periodontic and restorative prognosis with a minimum crown/root ratio of
50% and a life expectancy of at least five years. (MMPROG_)
3. Enamel “craze” lines or “imminent” or “possible” fractures: Anterior or posterior teeth that show a discolored
line in the enamel indicating a non-decayed defect in the surface enamel and are not a through-and through
fracture should be monitored for future changes. Crowns may be a benefit only when there is evidence of true
decay undermining more than 50% of the remaining enamel surface, or when there is a through-and-through
fracture identified radiographically or photographically, or when a portion of the tooth has actually fractured off
and is missing. Otherwise, there is no benefit provided for crown coverage of a tooth due to a “suspected future
or possible” fracture. (MM272)
4. Final crowns for teeth with a good prognosis should be sequenced after performing necessary endodontic
and/or periodontal procedures and such teeth should exhibit a minimum crown/root ratio of 50%.
5. Types of Crowns
a. When bicuspid and anterior crowns are covered, the benefit is generally porcelain fused to a base metal
crown or a porcelain/ceramic substrate crown.
b. When molar crowns are indicated due to caries, an undermined or fractured cusp or the necessary
replacement of a restoration due to pathology, the benefit is usually a base metal crown.
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c. Porcelain/ceramic substrate crowns and porcelain fused to metal crowns on molars may be susceptible to
fracture during occlusal function. Depending on the properties of the material used, it may not be
consistent with good clinical practice to routinely use all-porcelain/ceramic restorations on molar teeth.
d. Stainless steel crowns (Codes D2930 D2933) are primarily used on deciduous teeth and only used on adult
teeth due to a patient’s disability/inability to withstand typical crown preparation.
6. Crown and Bridge Unit Upgrades
a. Plan designs limit the total maximum amount chargeable to a member for any combination of upgrades to
$250 per unit.
b. Typical upgrades include:
i. Choice of metal noble, high noble
ii. Porcelain on molar teeth
iii. Based on the particular plan design, porcelain margins may be charged separately. A reasonable amount
may be charged ($100 or less per unit). A patient signed informed consent accepting the optional nature
and charge for this feature must be present.
iv. Grievances involving charges for upgrades will be found in favor of the Provider’s right to charge for
upgraded features only when a signed informed consent or treatment plan is present that meets the
“prudent layperson” requirement for clear disclosure of the proposed upgraded features, including risks,
benefits and alternatives. Members must have an option to access to their covered benefit as well as any
upgraded procedures.
7. Core Buildup, including any pins when required (Code D2950), must show evidence that the tooth requires
additional structure to support and retain a crown. (MM291)
a. Core buildup refers to building up of coronal structure when there is insufficient retention for an extra-
coronal restorative procedure.
b. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation.
8. Post and core (Code D2952 and D2954) procedures for endodontically treated teeth include buildups. By CDT
definitions, each of these procedures includes a “core.” Therefore, a core buildup, cannot be billed with either
Codes D2952 or D2954 for the same tooth, during the same course of treatment. (MMINC)
a. The tooth is functional, has had root canal treatment and the tooth requires additional structure to support
and retain a crown. (MM295) (MM299)
b. Post and core in addition to crown (Code D2952), is an indirectly fabricated post and core custom fabricated
as a single unit.
c. Prefabricated post and core in addition to crown (Code D2954) is built around a prefabricated post. This
procedure includes the core material.
9. Pin retention or restorative foundation may be medically necessary when a tooth requires a foundation for a
restoration. (MM2951)
10. A coping (Code D2975) or crown under a partial denture may be required when submitted documentation
demonstrates the medical necessity of the procedure. (MM297)
11. Repair of a restorative material failure may be medically necessary when submitted documentation establishes
restorative material failure. (MM298)
12. Outcomes: Standards set by the specialty boards shall apply.
a. Margins, contours, contacts and occlusion must be clinically acceptable.
b. Tooth preparation should provide adequate retention and not infringe on the dental pulp.
c. Crowns should be designed with a minimum life expectancy or service life of five years.
ENDODONTICS
A. Assessment
1. Diagnostic techniques used when considering possible endodontic procedures may include an evaluation of:
a. Pain and the stimuli that produce or relieve it by the following tests:
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i. Thermal
ii. Electric
iii. Percussion
iv. Palpation
v. Mobility
b. Non-symptomatic radiographic lesions
B. Treatment planning for endodontic procedures may include consideration of the following:
1. Strategic importance of the tooth or teeth
2. Prognosis endodontic procedures for teeth with a guarded or poor 5-year prognosis (endodontic, periodontal
or restorative) are not covered (MMPROG)
a. Excessively curved or calcified canals
b. Presence and severity of periodontal disease
c. Restorability and tooth fractures
3. Occlusion
4. Teeth that are predisposed to fracture following endodontic treatment should be protected with an appropriate
restoration; most posterior teeth should be restored with a full coverage restoration.
C. Clinical Guidelines
1. Diagnostic pre-operative radiographs of teeth to be endodontically treated must reveal all periapical areas and
alveolar bone.
2. A rubber dam should be used and documented (via radiograph or in the progress notes) for most endodontic
procedures. Documentation is required for any inability to use a rubber dam.
3. Gutta percha is the endodontic filling material of choice and should be densely packed and sealed. All canals
should be completely obturated.
4. Post-operative radiograph(s), showing all canals and apices, must be taken immediately after completion of
endodontic treatment.
5. In the absence of symptoms, post-operative radiographs should be taken at appropriate periodic intervals.
6. For direct or indirect pulp caps, documentation is required that shows a direct or near exposure of the pulp.
Direct or indirect pulp cap procedures are not considered bases and liners. (MM310)
a. Direct pulp capping is indicated for mechanical or accidental pulp exposures in relatively young teeth and
may be indicated in the presence of a small, exposed vital or normal pulp.
b. Indirect pulp capping (re-mineralization) is indicated to attempt to minimize the possibility of pulp exposure
in very deep caries in vital teeth.
7. For a pulpotomy (Code D3220) or pulpal therapy (Codes D3230 and D3240), documentation is required that
shows pulpal pathology and a good prognosis that the tooth has a reasonable period of retention and function.
(MM320) (MM232)
8. For endodontic treatment (Codes D3310 D3330), documentation is required that shows the treatment is
medically necessary (i.e., tooth is broken, decayed or previously restored, functional with an unhealthy nerve
and more than 50% of the tooth structure is sound) and the tooth has a good endodontic, periodontal and/or
restorative prognosis. (MM330) (MM300) (MM331E) (MM331P) (MM331R)
Note: LIBERTY may determine that a different, more appropriate procedure code better describes the endodontic
treatment performed and may make our determination based on the alternate code (MM330M)
9. For apexification/recalcification (Codes D3351D3353), documentation is required that shows the apex of the
tooth root(s) is/are incompletely developed. (MM335)
10. For apical surgery (Codes D3410 D3426), documentation is required that shows apical or lateral pathosis that
cannot be treated non-surgically and that the tooth has a good periodontal (MM340P) and restorative
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(MM340R) prognosis. (MM340) Endodontic apical surgical treatment should be considered only in specific
circumstances, including:
a. The root canal system cannot be instrumented and treated non-surgically.
b. There is active root resorption.
c. Access to the canal is obstructed.
d. There is gross over-extension of the root canal filling.
e. Periapical or lateral pathosis persists and cannot be treated non-surgically.
f. Root fracture is present or strongly suspected.
g. Restorative considerations make conventional endodontic treatment difficult or impossible.
Note: LIBERTY may determine that the apical surgery requested could have a better/equivalent outcome with a different
endodontic procedure code (MM340M)
11. For a retrograde filling (Code D3430), documentation is required that shows evidence of medical necessity for a
retrograde filling during periradicular surgery. (MM3430)
12. For a surgical or endodontic implant procedure (Code D3460), documentation is required that shows evidence
of medical necessity for the procedure. (MM345)
13. Endodontic irrigation
a. Providers are contractually obligated to not charge more than the listed copayment for covered root canal
procedures whether the dentist uses BioPure, diluted bleach, saline, sterile water, local anesthetic and/or
any other acceptable alternative to irrigate the canal. (MMINC)
b. Providers may not unbundle dental procedures to increase reimbursement from LIBERTY or enrollees. The
provider agreement and plan addenda determine what enrollees are to be charged for covered dental
procedures. BioPure as an alternative allowed on LIBERTY dental plans at no additional cost, whether or not
a choice is presented to the Member.
PERIODONTICS
A. Evaluations
1. All children, adolescents and adults should be evaluated for evidence of periodontal disease. If pocket depths do
not exceed 3 mm and there is no bleeding on probing or evidence of radiographic bone loss, it is appropriate to
document the patient’s periodontal status as being “within normal limits” (WNL).
2. In many cases a periodontal screening activity such as visual inspection, PSR® (Periodontal Screening and
Recording) evaluation of each sextant or other mechanism may provide sufficient information to make a
diagnosis or treatment plan.
3. Comprehensive oral evaluations should include the following:
a. Quality and quantity of gingival tissue
b. Documentation: six-point periodontal probing for each tooth
c. The location of bleeding, exudate, plaque and/or calculus
d. Significant areas of recession, mucogingival problems, level and amount of attached gingiva
e. Mobility
f. Open or improper contacts
g. Furcation involvement
h. Occlusal contacts or interferences
4. After a comprehensive evaluation, a diagnosis and treatment plan should be completed.
5. Sequential charting over time to show changes in periodontal architecture is of considerable value in
determining treatment needed or to evaluate the outcome of previous treatment.
B. Periodontal treatment sequencing
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1. Full mouth debridement to enable comprehensive evaluation and diagnosis (Code D4355) is “The gross removal
of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation.
This preliminary procedure does not preclude the need for additional procedures.” (CDT)(MM430)
a. In most cases, this procedure would be followed by the completion of a comprehensive evaluation at a
subsequent appointment. This rescheduling may allow some initial soft tissue response and shrinkage prior
to performing full mouth periodontal probing.
b. This procedure must be supported by radiographic or photographic evidence of heavy calculus, is not a
replacement code for a prophylaxis and is not appropriate on the same day as procedure comprehensive
oral evaluation or a comprehensive periodontal evaluation (codes D0150 or D0180). (MM430)
2. Scaling in the presence of generalized moderate or severe gingival inflammation (Code D4346) is "The removal
of plaque, calculus and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or
severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen,
inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. It should not be
reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures." (MM4346)
a. This procedure is for generalized moderate to severe gingival inflammation.
b. The ADA suggests that "generalized" would apply when 30% or more of the patient's teeth at one or more
sites are involved, which is analogous to the AAP definition of generalized chronic periodontitis.
c. The Loe & Silness Gingival Index can be a guideline for defining "moderate to severe inflammation"
i. Moderate inflammation - redness, edema, glazing; bleeding on probing
ii. Severe inflammation - marked redness and edema, ulceration; tendency toward spontaneous bleeding
iii. This is a therapeutic procedure, to treat a diagnosed disease.
iv. It is based on a diagnosis, not on intensity of treatment required.
v. It is appropriate for patients who do not have periodontitis (i.e. attachment loss).
vi. It is performed after a periodic or comprehensive exam.
vii. It can be performed on same date of service as the exam.
viii. It is a full mouth procedure, not a per quadrant procedure.
ix. Can be used for any age patient, and in any dentition stage (note that benefits vary by each member’s
plan design).
x. "...in conjunction with..." means on the same date of service. Prophylaxis and scaling and root planing
procedures may be performed at a future date, after Code D4346, as long as the codes thereafter are
used appropriately.
xi. Periodontal Maintenance (Code D4910) is not appropriate as a follow-up to Code D4346, since Code
D4346 isn’t performed to treat periodontal disease.
xii. Consider this procedure code when the patient's periodontium is not healthy, and the periodontal
disease diagnosis is limited to soft tissue (gingivitis) and is generalized but has not progressed to the
advanced disease stage with bone loss (periodontitis).
3. Scaling and Root Planing or SRP (Codes D4341, D4342)
a. Treatment involves the instrumentation of the crown and root surfaces of the teeth to remove plaque,
calculus, biofilm and stains from these surfaces. The absence of calculus should be evident on post
treatment radiographs.
i. This treatment is considered to be within the scope of a general dentist or a dental hygienist.
ii. It is common for radiographs to reveal evidence of bone loss of attachment and/or the presence of
interproximal calculus. It is supported when full mouth periodontal pocket charting demonstrates at
least 4 mm pocket depths. (MM400) If LIBERTY determines that there are too few teeth with a good
prognosis in each respective quadrant, we may approve an alternate, more appropriate code.
(MM400M)
iii. Scaling and root planing procedures (Codes D4341, D4342) are generally not performed in the same
quadrants or areas for 2 years following initial completion of these services. In the interim, any
CLINICAL DENTISTRY GUIDELINES
Clinical Criteria Guidelines
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localized scaling and root planing would be included within periodontal maintenance procedure (Code
D4910).
b. Scaling and root planing is not meant to be reported for an enhanced prophylaxis. If there is no bone loss, a
more appropriate code might be selected (Codes D1110 or D4346). Rather, it is the judicious removal of
deposits on the root surface in the presence of periodontal disease. In most cases some form of local
anesthesia would be indicated to properly render the scaling and root planing procedure. Thus, it would not
be considered good clinical practice to perform scaling and root planing in the absence of anesthetic.
c. It would not be considered good clinical practice to perform more than 2 quadrants of SRP at the same visit
(or, in most cases, on the same date of service) unless a medical or other condition is present that would
justify such AND there is demonstration of sufficient clinical treatment time to adequately perform judicious
scaling and root planing of the submitted quadrants. Per clinical review, in the absence of such information,
LIBERTY may limit the approval to no more than 2 quadrants on any given date of service. (MM401)
d. Definitive or pre-surgical scaling and root planing:
a. For early stages of periodontal disease, this procedure is used as definitive non-surgical treatment and
the patient may not need to be referred to a periodontist based upon tissue response and the patient’s
oral hygiene.
i. For later stages of periodontal disease, the procedure may be considered pre-surgical treatment and
the patient may need to be referred to a periodontist, again based on tissue response and the
patient’s oral hygiene.
ii. LIBERTY requires that both definitive and pre-surgical scaling and root planing be provided at a
primary care facility before considering referral requests to a periodontal specialist.
iii. Local anesthetic is commonly used. If it is not used, the reason(s) should be documented. The use of
topical anesthetics is considered to be a part of and included in this procedure.
iv. Home care oral hygiene techniques should be introduced and demonstrated.
v. A re-evaluation following scaling and root planing should be performed. This re-evaluation should be
performed at least 4-6 weeks later and include: a description of tissue response; pocket depth
changes; sites with bleeding or exudate; evaluation of the patient’s homecare ef