CurrentBlue Cross Blue Shield - MainePolicy 04-209

Guided Tissue Regeneration

Policy governing review and coverage criteria for dental guided tissue regeneration procedures for members under the plan; applies to providers submitting claims and requesting benefits for these procedures.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyGuided Tissue Regeneration

Policy CodePolicy 04-209

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain and submit diagnostic radiographs and current (within 12 months) 6-point periodontal charting showing pocket depths ≥ 5 mm for prior review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10listed criteria items

3CDT codes listed

12charting recency (months)

5min pocket depth (mm)

Coverage Criteria

General Indications / Coverage Criteria

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Primary anatomical indications: Procedure is generally confined to vertical, multi-walled or narrow defects with areas of vertical bone loss or Class II furcation defects; may be appropriate for Class II furcation involvement, vertical (intrabony and infrabony) defects, and use in conjunction with bone grafting.

Documentation requirements: Documentation must include diagnostic, recently dated, properly oriented, and identified radiographic images demonstrating vertical bone defects AND current (within 12 months) dated 6-point periodontal charting showing pocket depths of at least 5 mm.radiographs + charting (>= 5 mm; within 12 months)

Procedure limitations and contract dependencies: Procedures are generally limited to periodontal and peri-implant defects (dependent on group contract); benefits for use with dental implants may be allowed depending on group contract; the use of biologic materials for soft or osseous tissue regeneration will not be considered in conjunction with guided tissue regenerations.

Non-covered / Not routinely covered scenarios

Situations the policy identifies as typically not benefits-eligible or excluded.

Not covered scenarios: Guided tissue regeneration procedures associated with endodontic therapies or with minor periradicular surgery are typically not a covered benefit (bone heals by secondary intention); guided tissue regeneration is not considered for benefits when performed in conjunction with soft tissue grafting procedures.

The policy excludes concurrent use of separate biologic products intended for soft or osseous tissue regeneration when billed in conjunction with guided tissue regeneration procedures. Specifically, the use of biologic materials for soft or osseous tissue regeneration will not be considered in conjunction with guided tissue regenerations and such combined applications are not covered under this policy.

Guided tissue regeneration performed at the same time as soft tissue grafting is not a covered benefit. The policy states that guided tissue regeneration is not considered for benefits when performed in conjunction with soft tissue grafting procedures, and claims for procedures performed together should be evaluated as non-covered per this rule.

Coding

CDT codes (including but not limited to)CDT

D3432	Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery
D4266	Guided tissue regeneration - resorbable barrier, per site
D4267	Guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal)

ICD-10 (reference)ICD-10

IDC-10 CM

Diagnoses for Dental Diseases and Conditions: See the current CDT code book for details

inv-08: Periodontal pocket depth — >= 5 mm

Threshold>= 5 mm

Measurement method6-point periodontal charting

ContextRequired as part of documentation demonstrating necessity for guided tissue regeneration

Recency linkageCharting must be current (within 12 months) per policy documentation requirements

inv-09: Periodontal charting recency — within 12 months

Recency requirementWithin 12 months

Documentation typeDated 6-point periodontal charting

PurposeTo demonstrate current pocket depths meeting minimum threshold for procedure necessity

Policy linkagePart of required documentation for coverage determination of guided tissue regeneration

Provider Actions & Documentation Requirements

Prior Authorization

Documentation & Contract-dependent Coverage

Prior review/verification is implied by plan review requirements and documentation expectations; benefits and coverage depend on the member's contract.

Check the member's group contract for coverage details prior to performing guided tissue regeneration.
For major guided tissue regeneration (reconstructive) procedures, verify the patient's medical plan for possible coverage.

Denial Risk

Denial Risk — Procedure Exclusions

Provider must supply required documentation to support medical necessity; absence of required documentation may result in denial.

Guided tissue regeneration procedures associated with endodontic therapies or minor periradicular surgery are typically not covered — do not bill as covered when performed for these indications.
Guided tissue regeneration is not considered for benefits when performed in conjunction with soft tissue grafting procedures.

Documentation Required

Radiographic Image & Clinical Documentation Requirements

Radiographic and clinical documentation must be included and recent to support the procedure.

Include all associated diagnostic, recently dated, properly oriented, and identified radiographic images demonstrating vertical bone defects.
Provide current (within 12 months) dated 6‑point periodontal charting indicating pocket depths of at least 5 mm.
Document that the defect is vertical, multi-walled or narrow, or a class II furcation defect as applicable.

Documentation Required

Provider Action — Endodontic/Periradicular Procedures

Procedures tied to endodontic therapy or minor periradicular surgery are generally not eligible for benefits because bone often heals by secondary intention; confirm coverage before proceeding.

Do not expect coverage for guided tissue regeneration when associated with endodontic therapies or minor periradicular surgery unless explicitly covered by the group contract.

Background

Guided tissue regeneration is a periodontal surgical technique intended to promote regeneration of new bone, cementum, and periodontal ligament attachment to teeth that have been compromised by periodontal disease. It is generally indicated for localized vertical (intrabony/infrabony) defects and Class II furcation involvement, and is typically used for narrow or multi‑walled defects and may be used in conjunction with bone grafting where appropriate.

Coverage is contingent on meeting anatomical and documentation requirements: procedures are generally confined to vertical, multi‑walled or narrow defects with vertical bone loss or Class II furcation defects; documentation must include recently dated, properly oriented radiographs demonstrating vertical bone defects and current (within 12 months) 6‑point periodontal charting showing pocket depths of at least 5 mm. Benefits for use with dental implants are group contract dependent, and procedures associated with endodontic therapies or minor periradicular surgery are typically not covered. Post‑operative management is considered for the immediate three months after surgery and for any surgical re‑entry for up to three years, subject to group contract.

Definitions

inv-15: Guided tissue regeneration — A surgical procedure used to achieve new bone, cementum and periodontal ligament attachment to a periodontally diseased tooth.

DefinitionA surgical procedure used to achieve new bone, cementum and periodontal ligament (PDL) attachment to a periodontally diseased tooth.

Clinical usesMay be appropriate for Class II furcation involvement, vertical (intrabony/infrabony) defects, and use with bone grafting.

ScopeGenerally confined to vertical, multi-walled or narrow defects with areas of vertical bone loss or Class II furcation defects.