CurrentAnthemPolicy 07-901

Bone Grafts for Dental and Oral Surgical Services

Governs clinical appropriateness and use of bone grafting and bone graft substitutes in dental and oral surgical procedures for plan members and directs documentation and review requirements for submitting dentists.

Policy Summary

PayerAnthem

PolicyBone Grafts for Dental and Oral Surgical Services

Policy CodePolicy 07-901

Change TypeRevised (no material clinical changes)

Effective Date

Next Review Date

Key ActionSubmit current dated radiographs (within 12 months), a letter of rationale, recent health history, and periodontal chart as part of the clinical documentation for bone graft requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CDT codes listedprocedure codes referenced

3 monthspost-op mgmt period

3 yearssurgical re-entry window

within 12 morequired radiographs

Coverage criteria for bone grafts and substitutes

Appropriate Indications and General Review Criteria

Covered when ALL of the following are met:

Indication: Bone grafts are appropriate when replacing missing bone of the maxilla or mandible due to congenital anomalies, infection, or trauma.

Standards of Care: Procedure must meet generally accepted standards of dental practice (based on credible peer-reviewed dental literature, specialty society recommendations, and recognized practicing dentists) and be effective, not cosmetic, and not primarily for convenience.

Documentation: Submitting dentist must provide current (within 12 months), dated radiographic images, a letter of rationale explaining necessity and relation to other services, recent patient health history, and a recent dated periodontal chart if applicable; narrative and chart notes may be required.

Policy Summary

PayerAnthem

PolicyBone Grafts for Dental and Oral Surgical Services

Policy CodePolicy 07-901

Change TypeRevised (no material clinical changes)

Effective Date

Next Review Date

Key ActionSubmit current dated radiographs (within 12 months), a letter of rationale, recent health history, and periodontal chart as part of the clinical documentation for bone graft requests.

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.

Relevant procedure and diagnosis codes

Covered CDT codes (examples provided)CDTCovered

D6100	Implant removal, by report
D6103	Bone graft for repair of peri-implant defect
D6104	Bone graft at time of implant placement
D7295	Harvest of bone for use in autogenous grafting procedure
D7950	Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or non-autogenous, by report
D7951	Sinus augmentation via a lateral open approach
D7952	Sinus augmentation via a vertical approach
D7953	Bone replacement graft for ridge preservation
D7955	Repair of maxillofacial soft and/or hard tissue defect

Diagnosis coding referenceICD-10

ICD-10 CM

Diagnoses for dental diseases and conditions — see the current CDT code book for details

Provider requirements and review process

Documentation Required

Required clinical documentation

Requests for bone grafting procedures may be reviewed for appropriateness by dental professionals. Submitting dentists must include all relevant clinical information related to the procedural request, including recent, dated radiographic images (within 12 months), a letter of rationale explaining the necessity of the bone graft and whether it is related to another service, a recent patient health history, and a recent dated periodontal chart, if applicable. Narrative and chart notes may be required. Patients with medical complications or contraindications, poor oral hygiene, or habits that compromise healing (for example, cigarette or cigar smoking) must be considered when evaluating bone graft procedures.

Current (within 12 months), dated, diagnostic, pretreatment radiographic images required
Letter of rationale describing necessity and relation to other services required
Recent patient health history and periodontal chart (if applicable) required
Narrative and chart notes may be requested

Prior Authorization

Clinical review / authorization may be required

Requests may be subject to clinical review and authorization by dental professionals to determine appropriateness. Supporting clinical documentation as described in the Required clinical documentation callout should be submitted to avoid delays or denial.

Clinical review/authorization may be required for bone graft procedures
Submit supporting clinical documentation to demonstrate appropriateness

Documentation Required

Standards-based documentation

Services that meet generally accepted standards of dental care and are not primarily cosmetic should be supported by standards-based documentation. The conclusion that a service is medically or dentally necessary and/or appropriate does not guarantee that it is a covered benefit under the dental plan; benefit determination is subject to contract terms and plan coverage.

Support service with documentation that it meets generally accepted dental standards
Document that the service is not primarily cosmetic

Note

Medical plan coordination for major reconstructive grafts

For major reconstructive bone graft procedures, coordinate benefits with the patient’s medical plan as these procedures may be covered in whole or part by medical rather than dental benefits.

Check patient medical plan for coverage for major reconstructive bone grafts

Denial Risk

Adjunctive procedures related to non-covered primary service

When the primary procedure is not a covered service, all related adjunctive procedures (including bone grafts and use of membranes) that are tied to that primary, non-covered service are not a covered benefit even if they might be covered in other contexts.

Adjunctive procedures related to a non-covered primary service are not covered

Denial Risk

Insufficient documentation or contraindications may lead to denial

Requests lacking required documentation (for example, missing radiographs, letter of rationale, or relevant clinical records) or where contraindications exist may be denied. Bone graft procedures associated with endodontic therapies or minor periradicular surgery may not be benefitted as bone often heals by secondary intention. Routinely placing bone grafts into extraction sites may not be necessary for complete and adequate healing.

Insufficient documentation or presence of contraindications may result in denial
Bone grafts with endodontic or minor periradicular surgery typically not benefitted
Routine grafting of extraction sites may be unnecessary

Background and clinical context

Bone grafts are used to replace missing bone of the maxilla or mandible for reasons such as congenital anomalies, infection, or trauma. The policy frames appropriateness around generally accepted standards of dental practice and requires that requests be supported by adequate clinical documentation and patient‑specific considerations. Submitting dentists must provide current, dated radiographic images (within 12 months), a letter of rationale, recent patient health history, and a periodontal chart when applicable. Clinical review by dental professionals will consider medical complications, contraindications, poor oral hygiene, and habits that impair healing (for example, smoking) when determining whether bone graft procedures meet medical necessity criteria.

Standards and definitions

Generally accepted standards of dental practice — definition

DefinitionStandards based on credible scientific evidence published in peer-reviewed dental literature, specialty society recommendations or criteria, the views of recognized practicing dentists in the relevant clinical area, and other relevant credible sources.

ApplicationServices must be provided in accordance with these standards — appropriate in type, frequency, and extent; effective for the patient’s dental injury or disease; not primarily cosmetic or for convenience; and not more costly than an alternative service.

PurposeTo guide dental review and determine clinical appropriateness for bone grafting and related dental procedures.