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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will not pay for dental services. Dental services are items and services involving 
the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Medicare 
defines "structures directly supporting the teeth" as the periodontium, which includes the gingivae, 
dentogingival junction, periodontal membrane, cementum of the teeth, and alveolar process. You can find this 
rule in the Social Security Act, Section 1862(a)(12) and in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 150.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan's 
reference manual states criteria for Periodontal Treatment:
Not all procedures require authorization. Documentation needed for authorization of procedure:
- Radiographs - periapicals or bitewings preferred.
- Complete periodontal charting with AAP Case Type.
- Treatment plan.
Periodontal scaling and root planing, per quadrant involves instrumentation of the crown and root surfaces of 
the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease 
and is therapeutic, not prophylactic in nature. Root planing is the definitive procedure designed for the removal 
of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or
microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in 
some stages of periodontal disease and as a part of pre-surgical procedures in others. It is anticipated that this 
procedure would be requested in cases of severe periodontal conditions (i.e. late Type II, III, IV periodontitis) 
where definitive comprehensive root planing requiring local/regional block anesthesia and several 
appointments would be indicated. From the American Academy of Periodontology (AAP) Policy on Scaling 
and Root Planing:
"Periodontal scaling is a treatment procedure involving instrumentation of the crown and root surfaces of the 
teeth to remove plaque, calculus, and stains from these surfaces. It is performed on patients with periodontal 
disease and is therapeutic, not prophylactic, in nature. Periodontal scaling may precede root planing, which is 
the definitive, meticulous treatment procedure to remove cementum and/or dentin that is rough and may be
permeated by calculus or contaminated with toxins or microorganisms. Periodontal scaling and root planing are 
arduous and time consuming. They may need to be repeated and may require local anesthetic."
Criteria
- A minimum of four (4) teeth affected in the quadrant. Periodontal charting indicating abnormal pocket depths 
in multiple sites.
- Additionally at least one of the following must be present:
1) Radiographic evidence of root surface calculus.
2) Radiographic evidence of noticeable loss of bone support.
You can find this information in the Plan's Dental Office Reference Manual on pages 31-32.