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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield - Maine biologic materials …
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    CurrentBlue Cross Blue Shield - MainePolicy 03-401

    Biological Materials to Aid in Soft Tissue and Osseous Tissue Regeneration (Endodontic)

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    Policy governing use and coverage criteria for biological materials used to promote soft tissue and bone regeneration in dental/endodontic procedures for Blue Cross Blue Shield - Maine members.

    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyBiological Materials to Aid in Soft Tissue and Osseous Tissue Regeneration (Endodontic)
    Policy CodePolicy 03-401
    Change TypeNo material clinical or coverage changes
    Effective Date
    Last ReviewOct 25, 2024
    Next Review DateJan 1, 2025
    Key ActionObtain current (within 12 months) diagnostic periapical radiographs and 6‑point periodontal charting showing ≥5 mm pocket depths; submit prior authorization with a letter of rationale and material details when requested.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    >=12mrecency requirement for pretreatment radiographs
    >=5 mm

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    minimum pocket depth
    3example biologic materials listed
    3CDT codes listed

    Coverage Criteria

    Medical necessity criteria

    Covered when ALL of the following are met

    Entry criteria: 1) Current, dated (within 12 months), pretreatment periapical radiographic images that are of diagnostic quality; 2) Current, dated 6-point periodontal charting as described by American Academy of Periodontology (AAP) and American Dental Association (ADA) indicating a minimum of 5 mm pocket depths; 3) A letter of rationale explaining the necessity of the regeneration procedure and the type of material being used may be requested (examples: platelet rich plasma [PRP], Emdogain, recombinant human bone morphogenic protein [rhBMP], Gem-21S).

    Use of biological materials for soft tissue and osseous regeneration is subject to specific exclusions. Biologic materials will not be considered when used in conjunction with any of the following: soft tissue grafting, bone grafts, guided tissue regeneration, ridge augmentation, periradicular surgery, placement within extraction sites, or when combined with other regenerative materials regardless of group plan coverage. These exclusions apply even when the member’s group plan separately covers one or more of the listed procedures.

    Coding and Clinical Thresholds

    CDT codes (included examples)CPT
    D3431Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery.
    D4265Biological material to aid in soft and osseous tissue regeneration, per site.
    D7921Collection and application of autologous blood concentrate product.
    Diagnosis coding guidanceICD-10
    ICD-10 CMDiagnoses for Dental Diseases and Conditions - see the current CDT code book for details.
    Periodontal pocket depth — minimum requirement
    Minimum pocket depth>= 5 mm (current, dated 6-point periodontal charting per AAP/ADA)
    Charting recencyCharting must be current and dated within 12 months
    Charting method6-point periodontal charting per AAP/ADA

    Provider Actions and Requirements

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required. Submit current, dated (<12 months) pretreatment periapical radiographs of diagnostic quality, current, dated 6-point periodontal charting, and a letter of rationale explaining the medical necessity and the specific regenerative material(s) to be used (for example: PRP, Emdogain, rhBMP, Gem-21S). Additional documentation may be requested as part of the review.

    • Required at time of authorization: current dated periapical radiographs (<= 12 months)
    • Required at time of authorization: current dated 6-point periodontal charting showing minimum 5 mm pocket depths where applicable
    • Required at time of authorization: letter of rationale describing necessity and specific regenerative material(s) to be used
    Step Therapy

    Step Therapy / Coding Guidance

    No step therapy requirements apply. Coding lists below are informational only and do not guarantee coverage or reimbursement; verify member benefits.

    Background

    Tissue engineering and regenerative therapy use biological substitutes to restore, maintain, or improve tissue function by promoting regeneration of damaged soft tissue and bone rather than relying solely on autografts or allografts. Examples of biologic materials referenced in this policy include platelet rich plasma (PRP), Emdogain, recombinant human bone morphogenic protein (rhBMP), and Gem-21S. Regenerative therapy may be used to treat periodontal defects of natural teeth and dental implants and can be applied alone or in combination with other procedures when not excluded by the policy.

    Definitions

    Regenerative therapy / tissue engineering — definition
    DefinitionA process by which damaged tissues are regenerated using biological substitutes that restore, maintain, or improve tissue function, as an alternative to autografts or allografts.
    Clinical useUsed to treat periodontal defects of natural teeth and dental implants
    ScopeApplies to regenerative therapy utilizing biological materials whether used alone or with other procedures
    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyBiological Materials to Aid in Soft Tissue and Osseous Tissue Regeneration (Endodontic)
    Policy CodePolicy 03-401
    Change TypeNo material clinical or coverage changes
    Effective Date
    Last ReviewOct 25, 2024
    Next Review DateJan 1, 2025
    Key ActionObtain current (within 12 months) diagnostic periapical radiographs and 6‑point periodontal charting showing ≥5 mm pocket depths; submit prior authorization with a letter of rationale and material details when requested.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Clinical ThresholdsProvider Actions and RequirementsBackgroundDefinitions
    • Informational coding guidance only — inclusion/exclusion of codes does not imply coverage
    • Verify member contract benefits for coverage and reimbursement determination
    Documentation Required

    Required Documentation

    Documentation must include current, dated (within 12 months) pretreatment periapical radiographs of diagnostic quality and current, dated 6-point periodontal charting as described by AAP/ADA indicating a minimum of 5 mm pocket depths when applicable. The letter of rationale should state the clinical indication and specify the regenerative product or biologic to be used.

    • Radiographs: periapical images, diagnostic quality, dated within 12 months
    • Periodontal charting: 6-point AAP/ADA-style charting documenting pocket depths (minimum 5 mm where applicable)
    • Letter of rationale: clinical indication and specific regenerative material(s) to be used
    Denial Risk

    Denial Risk — Concomitant Procedures

    Use of biologic/regenerative materials may not be considered when performed in conjunction with other regenerative or adjunctive procedures. Examples of combinations that may be excluded include use with soft tissue grafting, bone grafts, guided tissue regeneration, ridge augmentation, periradicular surgery when placed within extraction sites, or when utilized with other regenerative materials regardless of specific plan coverage.

    • May not be considered when used with: soft tissue grafting, bone grafts, guided tissue regeneration, ridge augmentation, periradicular surgery
    • May not be considered when placed within extraction sites or used alongside other regenerative materials