CurrentAnthemPolicy 04-203

Biological Materials to Aid in Soft and Osseous Tissue Regeneration

Policies governing use and required documentation for biological materials (e.g., PRP, Emdogain, rhBMP) to aid periodontal and osseous tissue regeneration in dental practice where covered by specific group contracts.

Policy Summary

PayerAnthem

PolicyBiological Materials to Aid in Soft and Osseous Tissue Regeneration

Policy CodePolicy 04-203

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review DateN/A

Key ActionSubmit diagnostic-quality pretreatment periapical radiographs, current dated 6-point periodontal charting showing ≥5 mm pocket depths, and a provider letter of rationale when requesting coverage under a member's specific group contract.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D4265,D4266Example CDT codes listed

12 moRadiograph age

6-pointPeriodontal charting

>=5 mmMin pocket depth

Coverage Criteria

Coverage with criteria

Covered when ALL of the following are documented and coverage is provided by the member's specific group contract

Documentation requirements: Pretreatment periapical radiographic images that are of diagnostic quality, properly oriented, identified, and dated within 12 months; current, dated 6-point periodontal charting (as described by AAP and ADA) indicating a minimum of 5 mm pocket depths; and a letter of rationale explaining the necessity of the regeneration procedure and the type of biological material to be used (for example, PRP, Emdogain, recombinant human bone morphogenic protein [rhBMP], Gem-21S).radiograph <=12 months; pocket depth >=5 mm

Coverage is contingent on the member's specific group contract; required documentation may be requested for prior authorization.

Material use limitations: The use of biological materials may 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.

Documented limitation per policy.

Policy Summary

PayerAnthem

PolicyBiological Materials to Aid in Soft and Osseous Tissue Regeneration

Policy CodePolicy 04-203

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Diagnostic Requirements

CDT codes (informational)CPT

D4265	Biologic materials to aid in soft and osseous tissue regeneration Guided tissue regeneration resorbable barrier per site
D4266	Listed in document (see current CDT book for full description)

Radiograph age — within 12 months

Required agePretreatment periapical radiographs must be current — dated within 12 months.

Image qualityRadiographs must be diagnostic quality, properly oriented, and identified.

PurposeUsed to document baseline periapical status when requesting coverage for biologic regenerative materials.

Periodontal charting depth threshold — minimum 5 mm pocket depths

Minimum pocket depth6‑point periodontal charting must indicate a minimum of 5 mm pocket depths.

Charting methodUse current, dated 6‑point periodontal charting as described by the AAP and ADA.

Role in coverageDocumented pocket depths support medical necessity when group contract allows coverage for biologic materials.

Provider Actions and Documentation Requirements

Prior Authorization

Prior authorization / documentation requirement

When covered by specific group contract, prior authorization and supporting documentation are required. Documentation must be submitted to justify medical necessity for use of biologic materials for soft and osseous tissue regeneration.

Affected codes may include CDT D4265 and D4266 (see coding block).

Documentation Required

Required documentation

Required documentation when coverage is provided by the group contract: diagnostic-quality pretreatment periapical radiographs dated within 12 months; current dated 6-point periodontal charting (as described by the AAP and ADA) showing minimum 5 mm pocket depths; and a letter of rationale explaining the necessity of the regenerative procedure and the specific biologic material to be used (examples: platelet rich plasma (PRP), Emdogain, recombinant human bone morphogenic protein (rhBMP), Gem-21S).

Denial Risk

Documentation-linked denial risk

Failure to provide the required pretreatment periapical radiographs, current 6‑point periodontal charting showing the minimum pocket depth criteria, or a letter of rationale when requested may result in claim denial or payment reduction.

Denial risk applies when documentation is absent or incomplete per the group contract requirements.

Definitions

Regenerative therapy / tissue engineering

DefinitionProcess by which damaged tissues are regenerated using biological substitutes to restore, maintain, or improve tissue function; in dentistry used as adjunctive therapy for periodontal and osseous defects.

Examples of materialsIncludes biologic substitutes such as platelet rich plasma (PRP), enamel matrix derivative (Emdogain), recombinant human bone morphogenic protein (rhBMP), Gem-21S.

Clinical useApplied as adjunctive therapy to treat periodontal defects of natural teeth and dental implants in lieu of traditional grafts.

Letter of rationale

PurposeA provider‑authored explanation documenting the necessity of the regeneration procedure and specifying the biological material to be used (e.g., PRP, Emdogain, rhBMP, Gem-21S).

When requestedMay be requested as part of documentation when coverage is contingent on the member's specific group contract.

Role in reviewUsed by the plan to determine medical/dental necessity and appropriateness of biologic material use for the documented defect.

OpenPayer

Biological Materials to Aid in Soft and Osseous Tissue Regeneration

Coverage Criteria

Coding and Diagnostic Requirements

Provider Actions and Documentation Requirements

Background

Definitions