CurrentAnthemPolicy 07-901

Bone Grafts for Dental and Oral Surgical Services

This policy governs coverage and clinical requirements for bone grafting procedures of the maxilla and mandible for dental and oral surgical indications, and informs providers submitting requests to Anthem for members covered under applicable dental benefit plans.

Policy Summary

PayerAnthem

PolicyBone Grafts for Dental and Oral Surgical Services

Policy CodePolicy 07-901

Change TypeNo material changes

Effective Date

Next Review DateJan 1, 2025

Key ActionObtain prior authorization with recent dated radiographs (within 12 months), a letter of rationale, and relevant patient health history when submitting bone graft requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D6100-D7955CDT codes listed

3 monthsPost-op period

3 yearsSurgical re-entry

12 monthsRadiograph recency

NCApplicable state

Coverage and Medical Necessity Criteria

Medically necessary/coverage criteria

Covered when ALL of the following are met

Primary indications: Bone grafts may be appropriate when replacing missing bone of the maxilla or mandible as a result of congenital anomalies, infection, or trauma.

Documentation: Submitting dentists must include recent, dated radiographic images (current within 12 months), a letter of rationale explaining the necessity of the bone graft and whether it is related to another service, and a recent patient health history; narrative and chart notes may be required.

Patient suitability: Patients with medical complications or contraindications, demonstration of poor oral hygiene, or habits that compromise healing (eg, smoking) must be considered when evaluating candidacy for bone graft procedures.

Policy Summary

PayerAnthem

PolicyBone Grafts for Dental and Oral Surgical Services

Policy CodePolicy 07-901

Change TypeNo material changes

Effective Date

Next Review DateJan 1, 2025

Key ActionObtain prior authorization with recent dated radiographs (within 12 months), a letter of rationale, and relevant patient health history when submitting bone graft requests.

SourceLink

On This Page

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Coding and Documentation Requirements

Covered CDT Codes (examples listed)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 codesICD-10

ICD-10-CM

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

inv-07: Radiograph recency — Current (within 12 months)

Radiograph recencyCurrent (within 12 months) dated diagnostic pretreatment radiographic images are required

Documentation must includeRecent, dated radiographic images as part of required clinical documentation for prior authorization

Timeframe applies toPretreatment diagnostic radiographs submitted to support bone graft requests

Provider Obligations and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for bone graft requests. Submit a prior authorization request with all required clinical documentation to establish medical necessity before scheduling the procedure.

Include recent, dated diagnostic radiographic images (within 12 months).
Provide a letter of rationale explaining the medical necessity and whether the graft is related to another service.
Include recent patient health history and relevant chart notes.
Check the patient’s medical plan for coverage when major (reconstructive) bone grafting is proposed.

Documentation Required

Required Clinical Documentation

Provide complete clinical documentation with the submission. Documentation supports medical necessity determinations and avoids delays or denials.

Current (within 12 months), dated, diagnostic pretreatment radiographs must be included.
Narrative operative/clinical notes and chart documentation may be required.
Document patient-specific factors that affect healing (e.g., smoking, poor oral hygiene, medical complications or contraindications).

Note

Provider Actions

Provider actions summary — ensure all required items accompany the authorization to allow timely review.

Submit the letter of rationale describing necessity and relationship to other services.
Attach dated radiographs and recent health history when applicable.
State whether the graft is adjunctive to a covered primary service or related to a non-covered primary service.

Denial Risk

Denial/Billing Rule

Bone grafts submitted with non-covered primary procedures (including coronectomy) or tied to non-covered services will be denied as not a covered benefit.

Bone grafting when submitted with coronectomy is not a covered benefit.
Adjunctive procedures related to a non-covered primary service are not covered even if those adjuncts are covered in other contexts.
Bone graft procedures associated solely with endodontic therapies or minor periradicular surgery may not be benefitted because bone may heal by secondary intention.

Background

Bone grafting for oral surgical indications involves adding bone tissue to the maxilla or mandible to repair defects from congenital anomalies, infection, or trauma, to prepare implant sites, or to restore and enhance maxillofacial structure and function. Patient factors such as medical complications, contraindications, poor oral hygiene, or habits that compromise healing (for example, smoking) must be considered when evaluating candidacy for grafting.

Clinical requests for bone graft procedures must include documentation to support medical necessity: current (within 12 months) dated diagnostic pretreatment radiographs, a letter of rationale describing the necessity and relation to other services, and recent patient health history; narrative and chart notes may be required. Postoperative care is included for the immediate three months after surgery, with coverage for surgical re‑entry considered for three years depending on contract terms.

Definitions

inv-13: Bone graft procedures — definition and typical indications

DefinitionSurgical procedures that add bone tissue to the maxilla or mandible to repair fractures, prepare implant sites, correct deformities, or restore/enhance oral and maxillofacial structure and function; includes associated post-operative management for specified periods.

Typical indicationsReplacement of missing bone of the maxilla or mandible due to congenital anomalies, infection, or trauma

Post-operative coverage periodIncludes immediate post-operative management for three months and surgical re-entry coverage for three years (contract dependent)

Patient suitability considerationsMedical complications, contraindications, poor oral hygiene, and healing-compromising habits (eg, smoking) must be considered