Dental Policy Bulletins

Number: 008
(Updated)

Subject: Full-Mouth Debridement To Enable Comprehensive Evaluation and Diagnosis

Reviewed: August 12, 2013

Important Note

This Clinical Policy Bulletin expresses our determination of whether certain services or supplies are medically necessary. We have reached these conclusions based on a review of currently available clinical information including:
  • Clinical outcome studies in the peer-reviewed published medical and dental 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 and dentists practicing in relevant clinical areas
  • Other relevant factors

We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.

Policy

This procedure may be considered for coverage under certain dental plans. Treatment must be determined to be necessary, appropriate and consistent with the guidelines established by the American Academy of Periodontology (AAP) and the American Dental Association (ADA).

Background

The AAP defines active therapy as “surgical and/or nonsurgical periodontal therapies exclusive of full-mouth debridement.” Full-mouth debridement is intended for patients with excessive plaque and calculus that interferes with the ability of the dental professional to perform a comprehensive oral evaluation.1 Full-mouth debridement is considered a preliminary, non-therapeutic procedure. It is indicated in rare situations when the patient has not had a dental visit for a prolonged period of time.

Codes1

D4355 - Full-mouth debridement to enable comprehensive evaluation and diagnosis

Revision Dates

Original policy: April 12, 2005
Updated: March 15, 2006; May 24, 2010; April 25, 2011; May 21, 2012;August 12,2013
Revised: March 12, 2007; April 29, 2008; March 30, 2009

The above policy is based on the following references:

1American Dental Association. Current dental terminology, CDT 2013; 35.*
2American Dental Association. Dental practice parameters: Gingival inflammation with loss of connective tissue attachment (Periodontitis); 1994.
3American Academy of Periodontology. Parameter on comprehensive periodontal examination. J Periodontol. May 2000; 5 Suppl: 847-848.
4American Academy of Periodontology. Position paper: guidelines for periodontal therapy. J Periodontol. 2001; 72: 1624-1628.

*Current Dental Terminology. Copyright 2012 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.

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