Osseous surgery (D4260 / D4261) — payer documentation requirements

Aetna's DCPB012 classifies pocket-reduction surgery as dental-in-nature oral surgery and states no pocket-depth, bone-loss, or prior-therapy criterion; the published limit is typically one pocket-reduction surgery per quadrant or tooth in any 36 consecutive months.

• •Aetna treats the pocket-reduction codes as dental-in-nature oral surgery, coverable under either a medical or a dental plan
• •In dental plans that cover these periodontal services, the benefit is typically limited to one type of pocket-reduction surgery per quadrant or tooth in any 36 consecutive months — a cap shared across all pocket-reduction procedures, not one per code
• •The bulletin publishes no pocket-depth number, no radiographic bone-loss requirement, and no prior-scaling requirement for D4260 or D4261; Dentovio read the full bulletin on 2026-08-30 to confirm that absence
• •LANAP is not considered osseous surgery; where it meets Aetna's clinical guidelines for necessity it is benefited at the scaling-and-root-planing level

Frequency / timing: Typically one pocket-reduction surgery per quadrant or tooth in any 36 consecutive months, and only in plans that cover these periodontal services.

Verified 2026-08-30 · read from

Aetna DCPB012 — Periodontal pocket reduction surgery, revised March 13, 2026 (Policy and Codes sections)

Osseous surgery has its own named public policy in Cigna's DPPO guidelines, and the office reference guide bars both payment and any patient charge for same-office retreatment of a quadrant within 36 months.

• •Osseous surgery is covered by a named policy in the public DPPO guidelines (PERIO-06, D4260/D4261) — none of Cigna's periodontal criteria are portal-gated
• •The office reference guide lists retreatment of surgical periodontal services on the same quadrant within 36 months by the same dentist or dental office among the services for which there is no payment and no charge to the patient

Frequency / timing: No payment and no patient charge for same-office retreatment of surgical periodontal services on the same quadrant within 36 months.

Verified 2026-08-30 · read from

Cigna Dental Clinical Coverage Determination Guidelines — DPPO, 2026 edition, doc 928339 (PDF)Cigna Dental PPO dental office reference guide, form 988135 12/25 (PDF; also via CignaforHCP.com › Resources › Reference Guides)

Delta Dental Ins. defines osseous surgery by what the procedure must include — bone removal plus a full-thickness flap and direct reshaping of the alveolar process — and requires periodontal charting within 12 months.

• •The procedure must include the removal of supporting bone (ostectomy) and/or non-supporting bone (osteoplasty)
• •Procedures that do not include elevation of a full-thickness flap and closure, and direct surgical modification and reshaping of the bony support, do not qualify as osseous surgery
• •The submission table requires periodontal charting (probing) completed within the past 12 months for the periodontal surgical codes
• •For bone replacement grafts, benefits are generally allowable on vertical, multi-walled or narrow defects, and may not be allowed in areas of horizontal bone loss, class III furcation involvements, and broad interproximal defects
• •Grafts are not covered benefits when performed in conjunction with extractions, mucogingival surgery, periradicular surgery, implants, or ridge augmentation

Verified 2026-08-30 · read from

Delta Dental Ins. Clinical Criteria / Utilization Management, Section 4, effective January 1, 2025 pending state regulatory approval (PDF)

United Concordia denies osseous surgery as misreported where a dental advisor finds the reported quadrant does not show periodontal disease with moderate-to-deep pockets, evidenced by radiographic bone loss.

Scope: The first rule is from United Concordia's public PPO clinical policy; the frequency rule is the 2025 FEDVIP brochure and applies to that federal plan only.

• •The claim is denied as misreported where a dental advisor determines that the teeth in the reported quadrant do not show the presence of periodontal disease with moderate-to-deep pocket depths necessitating reshaping of the alveolar process, as evidenced by radiographic bone loss
• •Under the 2025 FEDVIP brochure the federal plan allows one periodontal surgical procedure per 24 months per area of the mouth

Verified 2026-08-30 · read from

United Concordia Dental Clinical Policy (PPO), last update 5.1.26 — public behind a no-login acknowledgement (PDF)United Concordia Dental FEDVIP brochure, 2025 plan year — Section 5, Periodontal Services (OPM)

Guardian publishes no code-specific osseous-surgery entry; a generic periodontal-surgical-services block applies, keyed to radiographic crest-height loss and charting, with any tooth at 50% or more bone loss excluded for poor prognosis.

• •There is no code-specific osseous-surgery entry in the public guidelines; a generic periodontal-surgical-services criteria block governs the surgical periodontal codes
• •Benefit may only be allowed with documentation of periodontal disease evidenced in radiographs and periodontal charting
• •Radiographs must show pathologic loss of alveolar crest height from the cementoenamel junction to the adjacent alveolar bone
• •Any tooth with 50% or more bone loss is excluded for poor periodontal prognosis
• •Radiographs must be pre-operative and taken within 24 consecutive months of the date of service and labelled with side, patient name, date and provider; periodontal charting must be within 12 months, and a panoramic radiograph alone is considered to have limited diagnostic value outside oral surgery

Published threshold: Radiographic pathologic loss of alveolar crest height from the CEJ; a tooth at 50% or more bone loss is excluded for poor prognosis.

Verified 2026-08-30 · read from

Guardian Dental Clinical Guidelines 2026, updated August 12, 2026 (PDF)

In DentaQuest's Texas Medicaid child program osseous surgery is covered for ages 13 to 20 with prior authorization or pre-payment review, full-mouth x-rays, periodontal charting and a narrative, once per quadrant per year.

Scope: DentaQuest's Texas Medicaid child (under-21) program. Criteria are state- and program-specific.

• •Covered for ages 13 to 20 in the Texas Medicaid child program
• •Prior authorization — or a documented pre-payment review, where that pathway is offered — is required before payment
• •The listed documentation is full-mouth x-rays, periodontal charting and a narrative
• •One service of osseous surgery per year, per patient, per quadrant
• •Requests to exceed a listed benefit limitation must be prior authorized with documentation supporting medical necessity — the limits are EPSDT floors, not absolute caps — and for emergency treatment documentation goes with the claim instead

Frequency / timing: One service per year, per patient, per quadrant.

Verified 2026-08-30 · read from

DentaQuest Texas Authorization Catalog — prior-authorization and pre-payment-review code table (PDF)DentaQuest Texas HHSC Medicaid/CHIP Office Reference Manual, © January 1, 2026 — Exhibit A and clinical criteria (PDF)

MCNA's Texas children's program covers osseous surgery for ages 13 to 20, once per quadrant per day per provider, alongside guided tissue regeneration and grafts in the same age band.

Scope: MCNA's Texas children's Medicaid book, birth through age 20.

• •Covered for ages 13 to 20
• •Limited to once per quadrant, per day, same provider
• •Guided tissue regeneration and the mucogingival and bone-graft codes carry the same 13-to-20 age band
• •Listed limits are EPSDT floors: requests to exceed them must be prior authorized with documentation supporting medical necessity

Frequency / timing: Once per quadrant, per day, same provider.

Verified 2026-08-30 · read from

MCNA Texas Medicaid and CHIP Provider Manual v1.31, effective March 1, 2026