CurrentAnthemPolicy 07-901

Dental Clinical Policy: Bone Grafts for Dental and Oral Surgical Services

Policy governing clinical indications, required documentation, and coverage limitations for bone grafting procedures of the maxilla and mandible in dental and oral surgery, including CDT codes and exclusions tied to non-covered primary procedures.

Policy Summary

PayerAnthem

PolicyDental Clinical Policy: Bone Grafts for Dental and Oral Surgical Services

Policy CodePolicy 07-901

Change TypeRevised (minor editorial refinements; intent unchanged)

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionProvider must include recent dated radiographic images, a letter of rationale explaining necessity and relation to other services, and recent patient health history when submitting for bone graft procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted; last revision included minor editorial refinements (10/31/2024) and intent remained unchanged.

16Listed CDT codes

12 monthsRadiograph recency requirement

3 monthsPost-op management included

3 yearsSurgical re-entry management

Policy 07-901: Bone Grafts for Dental and Oral Surgical Services — This policy governs clinical indications, required documentation, and coverage limitations for bone grafting procedures of the maxilla and mandible in dental and oral surgery, including referenced CDT codes and exclusions tied to non-covered primary procedures. Effective: 01/01/2026. Last review: 10/30/2025.

Surface threshold key-values

Radiographic recencyCurrent (within 12 months), dated, diagnostic, pretreatment radiographic images required

Post-operative management includedIncludes immediate post-operative management for 3 months following surgery

Surgical re-entry management periodManagement for any surgical re-entry included for 3 years (contract dependent)

Scope summaryPolicy governs clinical indications, required documentation, CDT codes, and coverage limits for maxilla/mandible bone grafting

Medical Necessity Criteria

General Coverage Criteria

Bone graft procedures may be considered when ALL of the following apply:

General Coverage Criteria - top level

Indication: Replacement of missing bone of the maxilla or mandible as a result of congenital anomalies, infection, or trauma
Submission requirements: Submitting dentist includes all clinical information related to the procedural request
Includes recent, dated radiographic images; a letter of rationale explaining necessity and relation to other services; and recent patient health history if applicable
Radiographic requirement: Current, dated, diagnostic, pretreatment radiographic images are providedwithin 12 months
Patient factors to consider: Consideration of patient's medical complications, contraindications, poor oral hygiene, or habits that compromise healing (e.g., smoking)
Documentation may be required: Narrative and chart notes may be required

Exclusions / Not Covered Conditions

Bone grafts are NOT covered when ANY of the following apply:

Exclusions - top level

Adjunctive to non-covered primary procedure: Primary procedure is not a covered service — all related adjunctive procedures (including bone grafts and membranes) related to that non-covered primary procedure are not a covered benefit
Endodontic/minor periradicular surgery: Bone graft procedures associated with endodontic therapies or with minor periradicular surgery
May not be benefited as typically bone heals by secondary intention
Routine extraction site grafting: Routinely placing bone grafts into extraction sites
May not be necessary for complete and adequate healing

Coverage Notes / Limits

Coverage Notes - top level

Immediate post-operative management: Bone graft procedures include post-operative management for the immediate three months following surgeryimmediate 3 months
Contract dependent
Surgical re-entry management: Bone graft procedures include management for any surgical re-entry for three years3 years
May require medical plan review / contract dependent
Major reconstructive grafts to medical plan: Major bone graft (reconstructive) procedures may be covered under the patient's medical plan
May require medical plan review

Coding

Included CDT Codes (bone graft / related surgical codes)mixedCovered

D6100	Implant removal, by report
D6103	Bone graft for repair of peri-implant defect
D6104	Bone graft at time of implant placement
D6105	Removal of implant body not requiring bone removal or flap elevation
D6106	Guided Tissue Regeneration (Implant Site, Resorbable Barrier)
D6107	Guided Tissue Regeneration (Implant Site, Non-Resorbable Barrier)
D7295	Harvest of bone for use in autogenous grafting procedure
D7921	Collection and application of autologous blood concentrate product
D7922	Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site
D7950	Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or non-autogenous, by report

1–10 of 16

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Diagnosis Codes ReferenceICD-10

ICD-10-CM diagnoses for dental diseases and conditions — see the current CDT code book for details (no specific ICD-10 codes listed)

Provider Actions & Billing Rules

Prior Authorization

Submit clinical documentation with request

When requesting prior authorization for bone graft procedures, include recent dated radiographic images, a letter of rationale explaining the necessity and relation to other services, and recent patient health history as applicable. Submit these items with the request to support medical necessity for the listed CDT codes.

D6100
D6103
D6104
D6105
D6106
D6107
D7295
D7921
D7922
D7950
D7951
D7952
D7953
D7955
D7956
D7957

Documentation Required

Provide narrative and chart notes on request

Narrative and chart notes may be required to support medical necessity and to evaluate contraindications or complicating factors.

Denial Risk

Adjunctive procedures tied to non-covered primary procedure

Claims for bone grafts and membranes related to a primary non-covered procedure will not be a covered benefit and may be denied.

Billing Rule

Post-operative management inclusion

Post-operative management for bone graft procedures is considered included for the immediate three months following surgery and for any surgical re-entry for three years (contract dependent).

Immediate post-operative management included for 3 months
Surgical re-entry management included for 3 years (contract dependent)

Background & Evidence

Bone grafting is performed to add bone tissue to the jaw to repair fractures, prepare implant sites, correct deformities, or restore structure and function of the oral and maxillofacial region. Note that major reconstructive grafts may be covered under the patient’s medical plan rather than the dental benefit. Definition — Bone graft procedures: procedures that add bone tissue to the jawbone, including autogenous and non-autogenous grafts, guided tissue regeneration, sinus augmentation, ridge preservation, and harvest of bone for grafting. The evidence base cited includes the World Workshop on Periodontal Classification (2018), American Academy of Periodontology systematic reviews, the Cochrane review (2021) on alveolar ridge preservation, and literature on bone graft techniques and efficacy.

Guideline and systematic review sources cited in the policy include the 2018 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions, AAP-commissioned and AAP best-evidence systematic reviews on biologics and bone augmentation techniques, the 2021 Cochrane review on alveolar ridge preservation techniques, and multiple reviews and clinical papers addressing bone graft materials and surgical techniques.