Initial periodontal therapy reevaluation (040)

Number: 040
Revised

Subject: Initial periodontal therapy reevaluation

Reviewed: July 12, 2024

Important note

This Clinical Policy Bulletin determines whether certain services or supplies are medically necessary, experimental, investigational, or cosmetic. Aetna® has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence -based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).

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Policy

We consider an interval of at least six weeks an appropriate and ideal time to reevaluate following periodontal scaling and root planing (CDT D4341/D4342). Reevaluation assesses the patient’s initial tissue response, before considering additional periodontal therapy. The reevaluation should be documented and include metrics such as periodontal pocket recordings.

Background

The primary function of reevaluation is to determine the effectiveness of scaling and root planing and to review the proficiency of home care.

The initial therapy’s outcome should be reevaluted after an appropriate interval for resolution of inflammation and tissue repair. A periodontal examination and re-evaluation may be performed with the relevant clinical findings documented in the patient’s record. These findings may be compared to initial documentation to assist in determining the outcome of initial therapy as well as the need for and the type of further treatment.

According to the American Academy of Periodontology and European Federation of Periodontology, depending on the treatment performed, patient reevaluation should occur at six weeks to three months post-therapy.  The consensus report from the most recent American Academy of Periodontology World Workshop indicates that a six-week interval is usually adequate to assess the initial response to therapy.

Codes

D0140 – Limited oral evaluation – problem focused
D0170 – Re-evaluation – limited, problem focused (established patient; not post-operative)
D0180 – Comprehensive periodontal evaluation – new or established patient
D4341 – Periodontal scaling and root planing – four or more teeth per quadrant
D4342 – Periodontal scaling and root planing – one to three teeth per quadrant

Revision dates

Original policy: March 17, 2015

Update: April 28, 2016; April 27, 2017; April 26, 2018; April 29, 2019; May 13, 2020; October 28, 2021; July 12, 2024

Revised: March 20, 2023

The above policy is based on the following references:

Decisions in Dentistry. July 2022;8(7)26-29.

American Dental Association. CDT 2024 Dental Procedure Codes.

Copyright 2024 American Dental Association. All rights reserved.

Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.