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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield - Maine Guided Tissue Regen…
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    CurrentBlue Cross Blue Shield - MainePolicy N/A

    Guided Tissue Regeneration (2026 Policy) PDF. Opens in a new window

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    Defines clinical indications, documentation requirements, limitations, and coding guidance for guided tissue regeneration procedures in dental care for Blue Cross Blue Shield - Maine. Applies to periodontal and peri-implant defects, with contract-dependent exceptions.

    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyGuided Tissue Regeneration (2026 Policy) PDF. Opens in a new window
    Policy CodePolicy N/A
    Change TypeRevised (no clinical changes)
    Effective DateJan 1, 2026
    Last ReviewOct 28, 2025
    Next Review Date
    Key ActionProvide dated, properly oriented pretreatment radiographs and current 6-point periodontal charting (within 12 months) showing pocket depths ≥ 5 mm as part of documentation of medical necessity.
    SourceLink
    POLICY UPDATE CHANGES

    Policy document status revised with last review dated 10/28/2025 and publish date 01/01/2026.

    5Primary covered clinical indications listed

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    3Contexts typically not covered
    12CDT codes listed (informational)

    Coverage Summary

    Guided tissue regeneration (GTR) is a surgical procedure intended to obtain new bone, cementum and periodontal ligament attachment to periodontally diseased teeth and is applied primarily for periodontal and peri-implant defects (contract dependent). Contract or plan terms may modify coverage for peri-implant or reconstructive procedures. Overall coverage stance is mixed — allowed for specific indications with documentation and limited or not covered in certain contexts.

    Policy metadata and threshold
    Effective date2026-01-01
    Last review date2025-10-28
    StatusRevised / CURRENT
    SubjectGuided Tissue Regeneration (dental)
    Threshold - Periodontal pocket depth>= 5 mm (documented on current within 12 months, post initial therapy 6-point periodontal charting)

    Medical Necessity Criteria

    General Coverage Criteria

    Guided tissue regeneration is considered when ALL of the following are met:

    • Anatomic indications: Procedure confined to vertical, multi-walled or narrow defects with areas of vertical bone loss or class II furcation defects.
    • Treatment site limitation: Treatment limited to periodontal and peri-implant defects (contract dependent).
    • Not covered contexts - endodontic/periradicular: Not covered when associated with endodontic therapies or minor periradicular surgery because bone heals by secondary intention.

      Typically not a covered benefit.

    Not Covered Contexts & Limitations

    Exclusionary contexts include procedures associated with endodontic therapies or minor periradicular surgery (typically not covered because bone heals by secondary intention), routine use for extraction sites (may not be necessary for adequate healing), procedures performed in conjunction with soft tissue grafting (not considered for benefits), and contract-dependent notes that benefits for peri-implant or implant-conjunction and major reconstructive procedures should be verified with the member’s contract or medical plan prior to treatment.

    Denial Risk

    Not covered contexts

    Claims for guided tissue regeneration associated with endodontic therapies, minor periradicular surgery, or performed in conjunction with soft tissue grafting procedures risk denial as these are typically not covered benefits. Affected code: D3432.

    • D3432

    Coding

    CDT procedure codes (informational)mixed
    D3432Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery
    D4266Guided tissue regeneration - resorbable barrier, per site
    D4267Guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal)
    D7956Guided tissue regeneration, edentulous area - resorbable barrier, per site
    D7957Guided tissue regeneration, edentulous area - non-resorbable barrier, per site
    ICD-10 CM DiagnosesICD-10
    No codes listed

    Provider Actions & Documentation Requirements

    Documentation Required

    Submit pretreatment radiographs

    Provide dated, properly oriented, pretreatment radiographic images demonstrating vertical bone defects as part of documentation of medical necessity. Images must be current (within 12 months).

    • within 12 months
    • vertical bone defects
    Documentation Required

    Submit periodontal charting

    Provide current (within 12 months), dated, post initial therapy 6-point periodontal charting indicating pocket depths of a minimum of 5 mm.

    • pocket depths >= 5 mm
    • current (within 12 months) post-initial therapy 6-point charting

    Background & Evidence

    Guided tissue regeneration is a surgical technique used to achieve new bone, cementum and periodontal ligament attachment to periodontally diseased teeth and is typically indicated for class II furcation involvement, vertical (intrabony/infrabony) defects, and as an adjunct with bone grafting.

    References include American Academy of Periodontology guidance (Parameters of Care and glossary) and multiple journal articles reporting outcomes of guided tissue regeneration, including studies on barrier membranes and long-term results of GTR therapy.

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

    Revision History

    2026-01-01policy_publishedLatest

    Policy document status revised and republished (is_material = false). Detail: History notes 'indications and criteria; intent unchanged' and prior revisions; no clinical policy statement changes were made. Last review dated 10/28/2025; publish date 01/01/2026.

    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyGuided Tissue Regeneration (2026 Policy) PDF. Opens in a new window
    Policy CodePolicy N/A
    Change TypeRevised (no clinical changes)
    Effective DateJan 1, 2026
    Last ReviewOct 28, 2025
    Next Review Date
    Key ActionProvide dated, properly oriented pretreatment radiographs and current 6-point periodontal charting (within 12 months) showing pocket depths ≥ 5 mm as part of documentation of medical necessity.
    SourceLink
    On This Page
    Coverage SummaryMedical Necessity CriteriaNot Covered Contexts & LimitationsCodingProvider Actions & Documentation RequirementsBackground & EvidenceRevision History
    Pretreatment radiographs:
    Documentation includes current (within 12 months), dated, properly oriented, pretreatment radiographic images demonstrating vertical bone defects.
  1. Periodontal charting: Documentation includes current (within 12 months), dated, post initial therapy 6-point periodontal charting indicating pocket depths of a minimum of 5mm.pocket depths >= 5 mm
  2. Not covered contexts - soft tissue grafting: Not considered for benefits when performed in conjunction with soft tissue grafting procedures.
  3. Implant conjunction: May be allowed when performed in conjunction with dental implants (contract dependent).
  4. Biologic materials exclusion: Use of biologic materials for soft or osseous tissue regeneration will not be considered in conjunction with guided tissue regenerations.
  5. Post-operative management: Includes post-operative management for the immediate three months following surgery as well as for any surgical re-entry for three years (contract dependent).
  6. Check medical plan for major procedures: For major guided tissue regeneration (reconstructive) procedures, check the patient's medical plan for coverage.
  7. Extraction sites: Routine performance of guided tissue regeneration for extraction sites may not be necessary for complete and adequate healing.

    Implies limited/rare coverage for extraction sites.

    8. Prior Authorization

    Check contract/medical plan for coverage

    Verify member contract and, for major reconstructive procedures, check the member's medical plan for coverage prior to proceeding. Coverage for peri-implant procedures and when performed in conjunction with dental implants is contract dependent.

    Billing Rule

    Post-operative management included

    Post-operative management for the immediate three months following surgery and any surgical re-entry for three years are considered part of the procedure (contract dependent).

    • post-op management included for 3 months
    • surgical re-entry included for 3 years