Service Descriptions and Limitations: Periodontal Services

(A) Surgical Periodontal Procedures. The MassHealth agency pays for gingivectomies and gingivoplasties once per member per quadrant every three calendar years. The MassHealth agency does not pay for a gingivectomy performed on the same day as a prophylaxis, periodontal scaling and root planing, or as a separate procedure with an extraction. The MassHealth agency pays for the gingivectomy or gingivoplasty for a maximum of two quadrants on the same date of service in an office setting. Gingivectomy or gingivoplasty procedure is performed to eliminate suprabony pockets or to restore normal architecture when gingival enlargements or asymmetrical or unaesthetic topography is evident with normal bony configuration. Prior authorization is required for members 21 years of age or older. (B) Periodontal Scaling and Root Planing. The MassHealth agency pays for periodontal scaling and root planing once per member per quadrant every three calendar years. The MassHealth agency does not pay separately for prophylaxis provided on the same day as periodontal scaling and root planing or on the same day as a gingivectomy or a gingivoplasty. The MassHealth agency pays only for periodontal scaling and root planing for a maximum of two quadrants on the same date of service in an office setting. Periodontal scaling and root planing involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus. It is indicated for members with active periodontal disease, not prophylactic. Root planing is the definitive procedure for the removal of rough cementum and dentin, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. Local anesthesia is considered an integral part of periodontal procedures and may not be billed separately. Prior authorization is required for members 21 years of age or older. (C) Non-surgical Scaling in the Presence of Generalized Moderate or Severe Gingival Inflammation - Full Mouth, after Oral Evaluation. The MassHealth agency pays for non-surgical scaling in the presence of generalized moderate or severe gingival inflammation, twice per member per calendar year. The MassHealth agency does not pay for scaling in the presence of generalized moderate or severe gingival inflammation on the same day as a prophylaxis, periodontal scaling and root planing, or surgical periodontal procedure, or as a separate procedure with a full mouth debridement or periodontal maintenance. This procedure includes 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 for members who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing.