CurrentAnthemPolicy 04-201

Dental Clinical Policy

Defines clinical appropriateness, documentation requirements, and coding guidance for bone grafting and related biologic/membrane materials used with periodontal and peri-implant procedures for Anthem dental benefit review.

Policy Summary

PayerAnthem

PolicyDental Clinical Policy

Policy CodePolicy 04-201

Change TypeRevised (annual revisions up to 10/24/2022)

Effective DateJan 1, 2023

Next Review Date

Key ActionSubmitting dentists must include recent, dated radiographic images, a letter of rationale, recent patient health history, and a recent dated periodontal chart (<12 months) following ADA reporting guidelines.

SourceLink

POLICY UPDATE CHANGES

Policy status shows Revised; revision history lists multiple annual revisions up to 10/24/2022.

9Key Criteria / Notes listed

10CDT codes referenced

12Peer-reviewed references cited

Coverage Summary

Policy 04-201 (effective 2023-01-01) addresses clinical appropriateness for Bone Grafts for Surgical Periodontal Services. The coverage stance is mixed, providing guidance on when bone grafting and related biologic/membrane materials may be appropriate for periodontal and peri-implant procedures.

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Medical Necessity Criteria

General Appropriateness

Bone grafts may be appropriate when ALL of the following are met:

ALL of the following

Replacing missing bone of the maxilla or mandible as a result of periodontal disease
Primary procedure is a covered service; when the primary procedure is not covered, all related adjunctive procedures (including bone grafts and membranes) are not covered
Submitted documentation includes recent, dated radiographic images, letter of rationale explaining necessity and relation to another service, recent patient health history, and a recent dated periodontal chart (less than 12 months old) following ADA reporting guidelinesRadiographs and chart < 12 months
Documentation includes diagnostic quality, recently dated (within 12 months), properly oriented, and labeled pretreatment radiographic images demonstrating vertical bone defectsRadiographs within 12 months
Current (within 12 months), dated post-initial therapy periodontal charting (6 point) indicating minimum pocket depth of 5 mmMinimum pocket depth 5 mm; charting within 12 months

Anatomic / Defect Criteria

Bone replacement procedures are generally appropriate when ANY of the following anatomic defect characteristics are present; see Limitations for items that are not appropriate or are limited:

ANY of the following

Vertical, multi-walled defects
Narrow defects
Class II furcation defects (loss of bone between roots, typically of molars)

Limitations

Broad horizontal interproximal defects generally do not respond well to bone graft procedures
Not appropriate

Adjunctive Materials and Timeframes

Coverage and benefit determinations for adjunctive biologic materials, membranes, and post-operative management are subject to the following conditions:

ALL of the following

The use of biologic materials for soft or osseous tissue regeneration may not be benefited in conjunction with bone grafts (group contract dependent)
Exclusion dependent on group contract
Bone procedures include post-operative management for the immediate three months following surgery as well as for any surgical re-entry for three years (group contract dependent)Post-op management: 3 months; re-entry follow-up: 3 years
Bone grafts are not considered for benefits when performed in conjunction with soft tissue grafting procedures
Not appropriate

Coding

Relevant CDT Codes (included but not limited to)mixed

D4263	Bone replacement graft - retained natural tooth - first site in quadrant
D4264	Bone replacement graft - retained natural tooth - each additional site in quadrant
D4265	Biologic materials to aid in soft and osseous tissue regeneration, per site
D4266	Guided tissue regeneration - resorbable barrier, per site
D4267	Guided tissue regeneration - non-resorbable barrier, per site
D4286	Removal of non-resorbable barrier
D6103	Bone for repair of peri-implant defect (does not include entry and closure/graft flap)
D6104	Bone graft at time of implant placement
D7295	Harvest of bone for use in autogenous grafting procedure

Provider Actions & Documentation Requirements

Documentation Required

Required submission materials

Submit recent, dated clinical documentation with requests for bone grafting: include dated radiographic images, a letter of rationale explaining the necessity and relationship to any other service, recent patient health history, and a recent dated periodontal chart (less than 12 months) following ADA reporting guidelines.

Recent, dated radiographs (pretreatment)
Letter of rationale explaining necessity and relation to other service
Recent patient health history
Recent dated periodontal chart (<12 months) following ADA reporting guidelines

Documentation Required

Pretreatment radiograph requirement

Provide diagnostic-quality pretreatment radiographs that are properly oriented and labeled, demonstrating vertical bone defects. Radiographs must be recently dated and within 12 months to be considered for benefit determination.

Proper orientation and labeling
Diagnostic quality images
Dated within 12 months (pretreatment radiograph recency threshold)

Documentation Required

Post-initial therapy charting

Include current (within 12 months), dated post-initial therapy periodontal charting using a 6-point periodontal chart. The chart must document that minimum pocket depths meet the policy threshold for consideration.

6-point periodontal chart (current within 12 months)
Documented minimum pocket depth of 5 mm

Denial Risk

Non-covered when primary procedure not covered

Claims for bone grafts and related adjunctive procedures may be denied when the primary procedure is not a covered benefit under the member's plan. Submitters should confirm that the primary procedure is covered before requesting payment for adjunctive services.

Documentation Required

Optional advanced imaging and records

Optional advanced records may be submitted and will be considered in benefit determinations. These records can supplement standard documentation when relevant to the requested procedure.

Current, dated cone‑beam CT (CBCT)
Intraoral or extraoral photos
Narrative and chart notes

Background & Evidence

This policy defines the scope and purpose as guidance on clinical appropriateness, documentation requirements, and coding for bone grafting and graft materials used with periodontal and peri-implant procedures. It outlines required submission materials (recent, dated radiographs, letter of rationale, patient health history, and a dated periodontal chart <12 months), defect and anatomic criteria, and limitations on use of grafts. The determination of medical necessity is for benefit review only and does not guarantee coverage under a member's plan.

Evidence cited includes peer-reviewed periodontal publications and coding guidance: peer-reviewed publications (multiple listed systematic reviews and clinical studies) and CDT 2023.

Revision History

2022-10-24revisionLatest

Annual Revision; revision history lists Annual Revision on 10/24/2022 (Committee). Note: non-material change flag present in brief (is_material=false).

2021-10-15revision

Annual Revision; Revised (Committee) on 10/15/2021.

2020-12-04revision

Annual Revision; Revised (Committee) on 12/4/2020.

2020-06-03revision

Annual Revision; Revised (Committee) on 6/3/2020.

2020-05-07revision

Corrected criteria (Corrected) on 5/7/2020.

2018-02-06revision

Revision (Related policies, Appropriateness/Medical Necessity) on 2/6/2018.

2017-02-08revision

Initial creation/Revision on 2/8/2017 (creation).