Maximizing Periodontal Surgery Insurance Reimbursement *

This document, along with the attached “Procedure Information” and “Insurance Carrier Reimbursement” grids will provide you with a tool
to maximize your patient’s insurance benefits and ensure you get paid for the treatment they need. As with all insurance maximizers, this
advice is not meant in any way to dictate diagnosis or treatment of your patients, nor is it meant to take any position on the “rightness” of
any carrier’s reimbursement strategy. Except as specifically mentioned, if a carrier will not pay for a specific treatment, your patient can be
given the option to pay for it as a non-covered procedure.

As with all treatment, the better radiographs, intraoral photos, and clinical notes you provide outlining the clinical necessity for and the
results of the treatment provided, the better probability you will have of getting paid. For periodontal surgery or any related periodontal
procedures, if there is any doubt on what the carrier or plan will pay, pre-authorize the treatment. If the carrier or plan will not authorize
reimbursement and the treatment is clinically necessary or the patient understands it’s cosmetic, you may charge the patient. This is
common for many procedures such as membranes (GTR), implants, and sinus augmentations. Similarly, if there are other limitations, such
as the number of soft tissue or bone graft sites a carrier or plan will reimburse, you may also charge the patient for these procedures using
the same guidelines. When emergency situations occur and it is not possible to pre-authorize treatment that should be pre-authorized, it is
strongly recommended to have the patient pay for the treatment and, if reimbursed by the carrier, refund the appropriate amount back to
the patient.

Below are the most commonly asked questions on periodontal reimbursement.

What pre-operative steps and documentation are crucial to secure reimbursement from the insurance carriers?
 Periodontal checklist including full breakdown of benefits. Various plans within same carrier provide vastly different benefits.
 Accurate and complete referral form. This is a straightforward but often missed requirement to secure HMO supplemental.
 Non-surgical attempts (SRP/PMT) and timelines, as required by each carrier, have been followed – Refer to Carrier Grid.
 Pre-authorize whenever necessary and on any large cases, whenever possible – Refer to Carrier Grid.
What general documentation are carriers looking for in order to pay for periodontal procedures?
 FMX taken within the past 3 years and continuing care x-rays less than 6 months old if needed to support clinical necessity.
 X-rays must be “text book,” showing undeniable clinical necessity.
 Intraoral photos both pre-op and post-op are crucial to get paid if x-rays don’t fully support clinical necessity (i.e., soft tissue
grafts).
 As applicable, pocket charting recorded: baseline, post SRP, and pre-op. Pre-op should generally be done by surgical provider.
Will carriers pay for consultation and periodontal surgery performed on the same day? Refer to Carrier Grid.
 For certain specific carriers, yes. This is a significant opportunity for additional reimbursement.
For the most frequently provided periodontal procedures, what are the essentials to ensure you get paid?
 Refer to the attached “procedure information” and the “carrier reimbursement” grids for specific details on gingivectomy
(D4210), crown lengthening (D4249), osseous surgery (D4260,D4261), bone graft (D4263,D4264), membrane/GTR
(D4266,D4267), soft tissue grafts (D4273,D4275, D4277), and implants (D6010).
Will plans reimburse for Emdogain (D4265)? If not, can I charge the patient?
 Many plans do not reimburse even though many PPO carriers have a fee on the fee schedule. Expect zero reimbursement.
 You may charge the patient for this. If the plan reimburses and patient has paid, refund the patient appropriate amount.
Will plans reimburse for sinus augmentation (D7951)?
 Not a benefit on most plans. Patient may be charged as long as it is not considered inclusive in other procedure.
 Plans with implant rider may provide a benefit. Always pre-authorize or have patient initially pay.
When will bone graft for ridge preservation (D7953) be reimbursed?
 Reimbursement is plan-specific and heavily correlated to the plan having implant coverage.
 Some carriers require bone graft be billed with the extraction and others for it to be billed with the implant. ALWAYS verify.
What criteria are carriers looking for to reimburse for a frenectomy (D7960)?
 Pre-op intraoral photos showing the location of a frenum and its impact on the surrounding gingiva and teeth.
 This is not paid if other surgical procedures are done on the same site and same service date (i.e., vestibuloplasty, gingivectomy,
or alveoplasty).
Should we expect reimbursement for occlusal adjustments (D9951)?
 Most PPO plans do reimburse. Some HMOs will reimburse as well; however, many have a zero fee.
What do most carriers consider standard post-operative care? Will a carrier reimburse for a later surgery on the same area?
 Most have 90-day/3-month post-operative care.
 Most have 3-year limitation to pay for surgical re-entry. May waive with strong clinical justification – Refer to Carrier Grid.

There will certainly be exceptions to each of the guidelines I have provided. Carriers change their positions regarding when they will or will
not pay for treatment, therefore affecting the payment of your claims. Please contact me with any information you may have, whether it is
now or in the future.
Amy Spaulding – (949) 306-2053
Senior Billing Operations Manager
* - certain recommendations adopted from “Coding with Confidence: the ‘Go To’ Dental Insurance Guide,” Charles Blair, D.D.S. CDT-2015/2016 Edition ISBN 978-0-692-47686-4
 Periodontal Surgery ‐ Procedure Information Grid
Narrative (in addition to
Periodontal Other Important
Procedure X‐rays Intraoral Photos documentation x‐ray, intraoral, Procedure Includes: Generally Not Paid If
Charting Information
PCH, etc.)

Suprabony pocket depth w/ firm

Baseline & post‐SRP fibrotic walls following root
showing pocket depth Provided with crown prep, Delta/DeltaCare SRP - must
Showing gingival instrumentation (SRPs). Improvement precede by six weeks or
FMX or pre‐operative x‐ of 5+mm recession, Distal wedge/gingival crown lengthening, frenectomy,
Gingivectomy defects supporting of soft tissue architecture, such as SRP is considered inclusive.
rays of the area being mobility, attached flap same area/same other restoration same
(D4210) need for treatment gingiva, sulcus depth, elimination of soft tissue craters,
treated DOS provider/same office. Osseous UCCI HMO 24 months SRP
(CRUCIAL) and width of irregular gingival margins, altered same quad/same DOS to D4210
keratinized gingiva passive eruption and/or for gingival
hyperplasia treatment
FMX including well‐ Any visible signs of Six-week healing period strongly
Include documentation of coronal Same day as crown/restorative
taken, current periapical decay reaching procedure; when osseous on same
recommended. Should be
fracture/caries below periodontal healthy tooth w/o perio
showing decay reaching below the bone area; removal of diseased bone;
Crown Pre‐op showing attachment; to further expose clinical involvement. GP should rough
below the bone level level Distal wedge same soft tissue removal; inadequate
Lengthening measurements on crown to allow proper crown prep and crown root ratio; cosmetic; “closed"
prep tooth for caries control. If
and insufficient crown area/same date treatment plan changes from
(D4249) treated tooth placement; removal of hard tissue in hard tissue laser procedure without
for retention (< 4mm crown lengthening to osseous,
otherwise periodontally healthy mouth; reflection of flap; more than
retention / 2mm discuss w/ GP and BC/SBC
overall perio condition of area/mouth once/tooth/lifetime
regarding the change
biological width)

Crown lengthening, SRP quadrants/dates &

Baseline and post‐ osseous contouring, any prior PMT w/ dates
FMX including well‐ distal/proximal wedge,
SRP showing showing increasing probing
taken periapical and Any visible signs of Document other essentials. Also, include SRP, gingivectomy,
pocket depth of frenectomy, Results in poor crown to root depth/loss of attachment. If
bitewings showing bone disease, including periodontal classification, area/tooth
5+mm (Guardian / frenuloplasty, ratio; excessive tooth mobility; deep sedation involved,
Osseous levels, horizontal and receding gums, numbers, need to gain access to achieve
MDG advise 6+ debridements, surgical advanced attachment loss; poor ensure properly
Surgery vertical defects, furca inflammation, more effective removal of reduction of fibrous
mm), mobility, prognosis; or patients who have recorded/records sent.
(D4260/D4261) involvement, increasing suppuration, and calculus/plaque in pockets. Necessity for tuberosity, perio
recession, attached demonstrated poor plaque Prior SRPs/other non‐
loss of attachment bleeding during surgical management due to non‐ maintenance, prophy,
gingiva, sulcus control surgical attempts not
(moderate to severe probing response to previous therapy anatomical crown
depth, and exposure, and any flap required in severe cases. If
bone loss)
keratanized gingiva procedures done on drug induced from meds,
same area/same date recommend pre‐ auth

Same as osseous with Same as osseous Same as osseous Support of osseous/gingival flap, Provided with ridge augmentation, Prior non‐surgical is the
Bone Graft specific focus on bony with specific focus with specific focus including treatment of vertical bony apicoectomies, extractions, same as osseous with
on bony defects on bony defects and implants, ridge preservation (use specific focus on bony
(D4263/D4264) defects and furcation defects or furcation involvement; natural 7953), cyst removal, or other non‐
involvement and furcation furcation tooth treated defects and furcation
perio surgical procedures
involvement involvement involvement
Same as bone
Same as bone graft w/ Same as bone graft graft w/ focus on Many carriers/plans do not
Not paid with bone graft
focus on class II w/ focus on class II class II furcation Same as bone graft w/ focus on pay.
Membrane/GTR exclusions as well as any soft
furcation involvement; furcation involvement; involvement; class II furcation involvement;
(D4266/D4267) available periodontal tissue grafts (4270, 4273, Confirm benefits and
available periodontal available available periodontal ligament
ligament 4275, 4277) limitations on all plans
ligament periodontal
ligament
Intraorals showing PCH baseline and post‐
UCCI PPO/misc. plans consider
gingival defects SRP (if periodontally If periodontally involved, perio class; integral to osseous same
Soft Tissue VERY IMPORTANT involved) showing tooth treated; patient's symptoms and Includes frenectomy, Aesthetic purposes; tooth brush area/DOS. UCCI PPO pays
pocket depth of 5+mm
Grafts (crucial to prove necessity for surgical management; distal wedge, abrasion; lack of attached 4273 as 4277 – patient
No x‐rays necessary recession, mobility,
responsible for difference.
(D4273/D4275/ recession and root attached gingiva, donor/harvest sites gingivectomy same tissue without disease or
D4277) exposure). Initial locations/measurements; any frenum site/same DOS additional risk factors Check coverage on all HMOs –
sulcus depth, and
coverage spotty especially on
picture and picture width of keratinized involvement
UCCI/Cigna
when open gingiva

All major HMOs no coverage. Pre‐authorize whenever

Full mouth arch or as a Extraction dates of all of the missing possible. If osseous being done
PPOs plan specific depending
Implants complete series. Post‐ teeth in the arch as well as the type and in same area, ensure it is on
on if they have implant rider. If pre‐auth. If not possible to pre‐
(D6010) op x‐rays after implant placement date of any previous
it is not covered, we can auth, have patient pay fee and
but before crown/bridge prosthesis
charge patient the entire fee refund if covered

Confidential and Proprietary – Pacific Dental Services, LLC

2/25/2016
 Periodontal Surgery ‐ Insurance Carrier Reimbursement Grid PPO
D0140 paid same day as D9310 paid same day Prior SRP/PMT before Osseous (4260/4261)/ Pocket Depth for Soft Tissue Sites/Quad (4273, 4275, Surgical Re‐ entry
Carrier Pre‐Auth ‐ * Crown Lengthening (D4249) Osseous Quads/Day ‐ ** Bone Graft (4263/4264) and Membrane (4266/4267) 4263/4266 Sites/Quad Emdogain (4265) Implants (6010)
treatment? as treatment? Gingivectomy (4210) Osseous 4277) Limitation ‐ +

Pre-authorize or
AETNA (except AZ) Suggested Over $350 Yes No 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 5 4 Charge Patient > 1 subject to review Rare coverage > 1 subject to review 3 years
charge patient
Pre-authorize or
Aetna (AZ) Suggested Over $300 Yes No 6 week healing; subject to review Prior attempts; no specifics 5 4 Charge Patient >1 subject to review Rare coverage >1 subject to review 3 years
charge patient
Pre-authorize or
Ameritas Suggested Over $200 Yes No 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 5 4 ^STBA 2 Most covered Covered, no specifics 3 years
charge patient
> 1 subject to review; D4275/D4277 Pre-authorize or
Assurant Benefit Suggested over $200 Yes Plan Specific 6 week healing; frequency: 1 in 3 years Prior attempts; no specifics 5 2 ^STBA 2 Not covered 3 years
not covered charge patient
Pre-authorize or
Banner Dental Over $200 Yes No 2 to 6 week healing; no frequency Minimum of 4 weeks prior 5 2 (4 quads needs detailed narrative) Both 4 Rare coverage 2 sites Subject to review
charge patient
Pre-authorize or
Blue Cross/Blue Shield None Required Yes Yes 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 5 2 (4 quads needs detailed narrative) 4263/4264 only 2 Rare coverage 2 sites 3 years
charge patient
Pre-authorize or
Blue Shield of CA Suggested over $500 Yes Yes 2 to 6 week healing; no frequency Minimum of 6 weeks prior 6 4 4263/4264 only 2 Not covered Not covered 3 years
charge patient
CCPOA Required Plan Specific Plan Specific 6 week healing; subject to review Prior attempts; pre-auth suggested 5 4 ^STBA Subject to review Not covered Subject to review Not covered No frequency limit
Pre-authorize or
Cigna Over $200 Yes No 6 week healing; pre-authorize > 1 site/quad Within 12 months of active therapy 5 4 Pay 4263, 4266 w/ class II furcation 2 Most covered 2 sites No frequency limit
charge patient
Recommend pre-
Delta Dental of AZ None Required Yes Yes 6 week healing; pre-authorize > 1 site/quad Minimum of 4 weeks prior 5 2 (4 quads needs detailed narrative) 4263/4264 only 2 Rare coverage 2 sites 3 years
authorization
Pre-authorize or
Delta Dental of CA None Required Yes Yes 6 week healing; pre-authorize > 1 site/quad Minimum of 4 weeks prior 5 2 (4 quads needs detailed narrative) ^STBA 2 Most covered 2 sites 3 years
charge patient
Pre-authorize or
Delta Dental of CO None Required Yes No 6 week healing; pre-authorize > 1 site/quad 30 days prior or 90 days following 5 2 (refer to note) ^STBA 2 Rare coverage 2 sites 3 years
charge patient
Pre-authorize or
Delta Dental of GA/FL Suggested over $300 Yes Yes 6 week healing; pre-authorize > 2 site/quad Minimum of 4 weeks prior 5 2 (4 quads needs detailed narrative) ^STBA 2 Rare coverage 2 sites 3 years
charge patient
Pre-authorize or
Delta Dental of ID None Required Yes Yes 6 week healing; subject to review Prior attempts; no specifics 5 2 (4 quads needs detailed narrative) Some pay 4263/4264, rare 4266/4267 2 Not covered 2 sites 3 years
charge patient
Delta Dental of KS Suggested over $250 Yes No 2 to 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 5 2 (4 quads needs detailed narrative) Both covered 2 Not covered 2 sites Not covered 3 years

Pre-authorize or
Delta Dental of LA Suggested over $300 Yes No 6 week healing; pre-authorize > 2 site/quad Minimum of 4 weeks prior 5 2 (4 quads needs detailed narrative) Both covered 2 Rare coverage 2 sites 3 years
charge patient
Pre-authorize or
Delta Dental of MN None Required Yes No 6 week healing; pre-authorize > 1 site/quad Minimum of 4 weeks prior 5 2 (refer to note) ^STBA 2 Rare coverage 2 sites 3 years
charge patient
Pre-authorize or
Delta Dental of MO None Required Yes No 6 week healing; pre-authorize > 1 site/quad Minimum of 4 weeks prior 5 2 (4 quads needs detailed narrative) ^STBA 2 Most covered 2 sites 3 years
charge patient
Pre-authorize or
Delta Dental of NM None Required Yes No 6 week healing; pre-authorize > 1 site/quad 30 days prior or 90 days following 5 2 (4 quads needs detailed narrative) ^STBA 2 Most covered 2 sites 3 years
charge patient
Pre-authorize or
Delta Dental of OR (ODS) Suggested over $300 Yes Yes 6 week healing; subject to review Prior attempts; no specifics 5 2 (4 quads needs detailed narrative) ^STBA > 1 subject to review Subject to review Subject to review 3 years
charge patient
Pre-authorize or
Delta Dental of TN Suggested over $250 Yes No 6 week healing; subject to review Prior attempts; no specifics 5 2 (4 quads needs detailed narrative) Both covered 2 Not covered Subject to review 3 years
charge patient
Pre-authorize or
Delta Dental of TX Suggested over $300 Yes Yes 6 week healing; pre-authorize > 2 site/quad Minimum of 4 weeks prior 5 2 (4 quads needs detailed narrative) Both covered 2 Rare coverage 2 sites 3 years
charge patient
Pre-authorize or
Delta Dental of VA & WA Suggested over $300 Yes No 6 week healing; pre-authorize > 1 site/quad Minimum of 4 weeks prior 5 2 ^STBA 2 Rare coverage 2 sites 3 years
charge patient
Recommend pre-
Delta Dental Tricare Suggested over $300 Yes No 6 week healing; pre-authorize > 1 site/quad 30 days prior or 90 days following 5 2 ^STBA 2 Rare coverage 2 sites 2 years
authorization
Pre-authorize or
GEHA Connection Dental None Required Yes No 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 5 2 (4 quads needs detailed narrative) Charge Patient Not covered Not covered Subject to review 2 years
charge patient
Pre-authorize or
Guardian None Required Yes No 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 6 4 ^STBA All subject to review Not covered 2 sites 3 years
charge patient
Pre-authorize or
Humana Suggested over $300 Yes Yes 6 week healing; pre-authorize > 1 site/quad Minimum of 94 days prior 5 4 ^STBA >1 subject to review Not covered > 1 subject to review 3 years
charge patient
Pre-authorize or
Liberty Mandatory Yes No 6 week healing; pre-authorize > 1 site/quad Minimum of 12 weeks prior 5 2 ^STBA All subject to review Subject to review Subject to review No frequency limit
charge patient
Recommend pre-
MetLife Recommend Yes No 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 5 4 Both covered 2 Most covered 2 sites 3 years
authorization
Pre-authorize or
Premier Access Recommend Yes No Subject to Review Prior attempts; no specifics 5 4 ^STBA 4 Subject to review Subject to review 3 years
charge patient
Pre-authorize or
Principal Financial Group Recommend Yes No 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 5 4 4263/4264 only 2 Not covered >1 subject to review 3 years
charge patient
> 1 subject to review (pay 4273 as Pre-authorize or
United Concordia (Except AZ) Suggested over $300 Yes No 6 week healing; pre-authorize > 1 site/quad Minimum of 4 weeks prior; maximum of 24 months 5 2 (refer to note) If 4266 denied will deny 4263 & 4260 & require appeal > 1 subject to review Not covered 3 years
4277) charge patient
Pre-authorize or
United Concordia (AZ) Suggested over $300 Yes No 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 5 2 (4 quads needs detailed narrative) ^STBA Subject to review Subject to review Subject to review 3 years
charge patient
Pre-authorize or
United Health Care Mandatory Yes Yes 6 week healing; pre-authorize > 1 site/quad No specifics 5 4 4263/4264 only >1 subject to review Some coverage > 1 subject to review 3 years
charge patient
* ‐ All large cases should be pre‐authorized.
** ‐ Carriers that indicate only pay 2 quads/day will pay for 4 for patients with systemic health conditions or high risk factors.
+ ‐ Carrier may waive limitation with strong clinical justification. Pre‐authorize all instances of such a request.

^STBA - Subject to Benefits Adjudication - Initially charge patient; may need to subsequently adjust/refund based on receipt of actual EOB (can't be determined by elegibility check).
General Note ‐ When treatment is not covered/not paid, the patient can be charged a fee for the procedure. Always confirm benefits on each patient plan as some plans differ from the overall carrier. As with previous guidelines, there will be exceptions to the recommendations provided. Carriers often will change their positions on when they will or will not pay for treatment.

Confidential and Proprietary ‐ Pacific Dental Services, LLC 9/27/2018

 Periodontal Surgery ‐ Insurance Carrier Reimbursement Grid HMO
D0140 paid same day as D9310 paid same day Prior SRP/PMT before Osseous (4260/4261)/ Pocket Depth for Soft Tissue Sites/Quad (4273, 4275, Surgical Re‐ entry
Carrier Pre‐Auth ‐ * Crown Lengthening (D4249) Osseous Quads/Day ‐ ** Bone Graft (4263/4264) and Membrane (4266/4267) 4263/4266 Sites/Quad Emdogain (4265) Implants (6010)
treatment? as treatment? Gingivectomy (4210) Osseous 4277) Limitation ‐ +

Refer to patient plan

Aetna HMO Suggested over $350 Yes Yes 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 5 4 Charge Patient > 1 subject to review Subject to review Not covered 3 years
schedule
Refer to patient plan
Aetna HMO (AZ) Suggested over $350 Yes Yes 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 5 4 Charge Patient Subject to review Subject to review Not covered 3 years
schedule
Refer to patient plan
Blue Cross HMO Mandatory Yes Yes 6 week healing; pre-authorize > 1 site/quad Minimum of 4 weeks prior 5 2 (4 on appeal) Charge Patient 2 2 sites Not covered 3 years
schedule
Refer to patient plan
Cigna HMO Direct Referral Yes No 6 week healing; pre-authorize > 1 site/quad Within 12 months of active therapy 5 4 4263 or 4266 not both (when on fee schedule) 2 2 sites Not covered No frequency limit
schedule
Refer to patient plan
DeltaCare HMO Mandatory Yes No 6 week healing; pre-authorize > 1 site/quad Minimum of 4 weeks prior 5 2 (4 quads needs detailed narrative) 4263 only (when on fee schedule) 2 2 sites Not covered 3 years
schedule
Refer to patient plan
Managed Dental Guard HMO Direct Referral Yes No 6 week healing; pre-authorize > 1 site/quad Minimum of 1 month prior; maximum of 12 months Recommend 6 4 Charge Patient All subject to review 2 sites Not covered 3 years
schedule
Refer to patient plan
Safeguard HMO Direct Referral Yes Yes 6 week healing; pre-authorize > 1 site/quad Prior attempts; no specifics 5 4 Charge Patient All subject to review 2 sites Not covered 3 years
schedule
Refer to patient plan
United Concordia HMO Direct Referral Yes No 6 wk healing; auth; > 1 site/quad Minimum of 4 weeks prior; maximum of 24 months 5 2 (refer to note) Charge Patient > 1 subject to review > 1 subject to review Not covered 2 years
schedule

* ‐ All large cases should be pre‐authorized.

** ‐ Carriers that indicate only pay 2 quads/day will pay for 4 for patients with systemic health conditions or high risk factors.
+ ‐ Carrier may waive limitation with strong clinical justification. Pre‐authorize all instances of such a request.

^STBA - Subject to Benefits Adjudication - Initially charge patient; may need to subsequently adjust/refund based on receipt of actual EOB (can't be determined by elegibility check).
General Note ‐ When treatment is not covered/not paid, the patient can be charged a fee for the procedure. Always confirm benefits on each patient plan as some plans differ from the overall carrier. As with previous guidelines, there will be exceptions to the recommendations provided. Carriers often will change their positions on when they will or will not pay for treatment.

Confidential and Proprietary ‐ Pacific Dental Services, LLC 9/27/2018