INSURANCE CONNECTION
After fielding numerous phone calls from members in reference to the issue of the claim submission process for scaling and root planing ( S / RP ), PDA went directly to the source — the insurers — for answers . We asked the insurers for information on their internal policies so that we could in turn provide them to you , in order to help you understand what exactly they are looking for before approving your claims , ultimately alleviating administrative hassles for both you and the insurer , and ensuring prompt payment for you and your patients .
To date , we have received responses from four insurers : Cigna *, Delta Dental , Dominion Dental and United Concordia ( UCCI ). The following information is intended as a guide only , to help you understand the different claims submission process for each insurer . For clarification or to ask additional questions , please be sure to contact your insurance company representatives directly .
PDA Question : In regards to D4340 , D4341 and D4342 , please list the requirements necessary for approval of benefits in regards to radiographs , probing depths , charting requirements , etc .
Cigna : Cigna requires a current and dated periodontal charting ( within the last six months ) along with a diagnosis and treatment plan . The periodontal charting should include six point probing for each tooth . Missing teeth and teeth planned for extraction should be noted . Full mouth radiographs should be included to demonstrate bone / attachment loss . If necessary , a narrative should be included describing any unusual circumstances .
Four or more teeth per quadrant must be involved for D4341 ; if fewer than four teeth per quadrant are involved , then D4342 is the appropriate code . Code D4340 is not listed as a current CDT-2013 code . Cigna Delta does not recognize code D4340 .
Delta Dental : The current requirement for periodontal scaling and root planing are outlined in the Delta Dental Dentist Handbook , pages 4-24 and 4-25 . Periodontal scaling and root planing is benefited for patients who are at least periodontal class II ( 4-6 millimeter pocket depths ); radiographic images currently are not required .
Dominion Dental : ➢ Perio Charting — charting must show pocket depths of 5mm or more . ➢ X-rays for each quad claimed must be submitted . ➢ Bone loss should be visible radiographically — if not visible , claim may still be approved , based on clinical claim review .
UCCI : ➢ Full mouth duplicate radiographs or digital images . ➢ Full mouth charting , including 6 points per tooth . ➢ Detailed narrative describing the clinical findings that justify the need to plane the root surfaces .
( Please note that code D4340 is no longer a valid CDT code )
PDA Question : If radiographic evidence of bone loss is a necessity for the benefitting of scaling and root planing , what amount of bone loss is necessary and from what reference point is that loss measured in order to benefit scaling and root planing ?
Cigna : There is no specified amount or radiographic bone loss necessary . Cigna ’ s determination is based primarily upon reported pocket depths as supported by evidence of any radiographic bone loss .
Delta Dental : Radiographic images currently are not required or reviewed during the claims adjudication process for scaling and root planing . The current qualifying condition for scaling and root planing is based on pocket depth , with a minimum of 4 mm pocket depth on the diseased teeth involved .
Dominion Dental : Radiographic evidence of bone loss is generally required , unless the claim includes a narrative indicating extenuating medical circumstances . Bone loss is quantified by radiographic evidence of loss of soft tissue attachment and loss of bone support . The scaling of calculus and / or bacterial deposits from enamel surfaces , supragingival or subgingival , does not constitute root planing .
UCCI : The diagnostic materials must show : ➢ Radiographic evidence to support the loss of periodontal attachment as determined by our advisors .
➢ Radiographic evidence of crestal bone loss measured from the CEJ to such an extent that most dentists would diagnose active periodontitis and recommend S / RP in the opinion of our advisors .
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