Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 420.000 - Dental Services › Section 420.427 - Service Descriptions and Limitations: Periodontal Services

Current through Register 1525, July 5, 2024
(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