CurrentAnthemPolicy 04-203

Biological Materials to Aid in Soft and Osseous Tissue Regeneration

Defines indications, documentation requirements, exclusions, and informational coding for use of biologic materials to aid soft and osseous tissue regeneration in dental practice when covered by specific group contracts. Applies as a clinical policy to guide determinations of dental medical necessity and review.

Policy Summary

PayerAnthem

PolicyBiological Materials to Aid in Soft and Osseous Tissue Regeneration

Policy CodePolicy 04-203

Change TypeRevised (Annual Review)

Effective DateJan 1, 2024

Next Review Date

Key ActionProvide pretreatment periapical radiographic images and current 6-point periodontal charting showing at least 5 mm pocket depths to support use of biologic materials.

SourceLink

POLICY UPDATE CHANGES

Policy revised with last review date 10/04/2023 and published date 01/01/2024.

3Required documentation items

3CDT codes listed (informational)

5 mmPocket depth threshold

Coverage Summary

Policy addresses biologic materials used to regenerate damaged periodontal and osseous tissues as adjunctive therapy in dentistry. The plan performs review of these biologic materials due to contractual requirements and may require that services meet generally accepted standards of dental care; determinations of medical or dental necessity are contract-dependent and do not guarantee that a service is a covered benefit payable by the dental plan.

Documentation and Indications for Use

When covered by specific group contract; indications for the use of biologic materials must be documented by:

ALL of the following

Pretreatment radiographs: Pretreatment periapical radiographic images that are of diagnostic quality, properly oriented, and identified, and dated current (within 12 months).dated within 12 months
Periodontal charting: Current; dated periodontal charting (6-point periodontal charting) indicating a minimum of 5 mm pocket depths.>= 5 mm
Rationale may be requested: Rationale in support of the regeneration procedure and the type of material being used may be requested (e.g., recombinant human bone morphogenic protein (rhBMP), GEM 2150).
May be requested — not mandatory in all cases; supports medical necessity determination.
Exclusion/limitation: Biological materials should not be considered when used in conjunction with soft tissue grafting, bone grafts, guided tissue regeneration, ridge augmentation, periradicular surgery, placed within extraction sites, or when utilized with other regenerative materials regardless of specific group plan coverage.
This is an exclusion/limitation to use in conjunction with listed procedures.

Required Provider Actions

Documentation Required

Submit diagnostic radiographs and periodontal charting

Provide pretreatment periapical radiographic images (diagnostic quality, properly oriented, identified, dated within 12 months) and current dated 6-point periodontal charting showing at least 5 mm pocket depths to support use of biologic materials.

D3431
D4265
D4266

Documentation Required

Provide rationale for material selection

Be prepared to provide a rationale supporting the regeneration procedure and the specific biologic material selected (examples: recombinant human bone morphogenic protein (rhBMP), GEM 2150).

Denial Risk

Use with listed procedures is not considered

Claims for biologic materials used in conjunction with soft tissue grafting, bone grafts, guided tissue regeneration, ridge augmentation, periradicular surgery, placed within extraction sites, or with other regenerative materials may not be considered for coverage.

Soft tissue grafting
Bone grafts
Guided tissue regeneration
Ridge augmentation
Periradicular surgery
Placed within extraction sites
Utilized with other regenerative materials

Background and Evidence

This document addresses biologic materials to aid in soft and osseous tissue regeneration whether used alone or with other procedures, and clarifies that reviews are performed because plan contracts may require services to meet generally accepted standards of dental care. The conclusion that a service is medically necessary does not guarantee coverage; federal, state and specific contract language take precedence and the plan may modify policies as needed.

Selected literature references include multiple peer-reviewed studies and specialty society resources on enamel matrix derivatives (e.g., Emdogain), recombinant human bone morphogenic proteins (rhBMP), platelet-rich plasma and related regenerative techniques, and American Academy of Periodontology position papers and commissioned reviews.

Definitions

Policy Metadata

Revision History

2023-10-04Annual Review

Policy revised with last review date 10/04/2023; no clinical-policy-statement changes indicated.

2024-01-01Published / EffectiveLatest

Published/effective date 01/01/2024 reflecting the revision noted on 10/04/2023; no clinical-policy-statement changes indicated.