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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield Maine guided tissue regener…
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    CurrentBlue Cross Blue Shield - MainePolicy 04-209

    Guided tissue regeneration (dental) coverage criteria

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    Policy governing coverage and clinical criteria for guided tissue regeneration procedures for periodontal and peri-implant defects for Blue Cross Blue Shield - Maine members.

    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyGuided tissue regeneration (dental) coverage criteria
    Policy CodePolicy 04-209
    Change TypeNo material changes
    Effective DateJan 1, 2025
    Last ReviewOct 28, 2024
    Next Review DateJan 1, 2025
    Key ActionObtain and include current (within 12 months) dated radiographs and post-initial therapy 6-point periodontal charting showing pocket depths ≥5 mm; prior authorization may be required per contract.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    10policy criteria points
    6example CDT codes
    12 mo

    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.

    radiograph/charting timeframe
    3 mo / 3 yrpost-op inclusion

    Coverage Criteria

    Covered with specified clinical criteria

    Guided tissue regeneration is covered when ALL of the following are met (contract dependent where noted):

    Primary anatomic indications: Defect is vertical, multi-walled or narrow with areas of vertical bone loss or a Class II furcation defect

    See clinical indications

    Procedure scope: Procedure is for treatment of periodontal or peri-implant defects (coverage for implants is contract dependent); procedures associated with endodontic therapies or minor periradicular surgery are typically not covered

    Not considered when performed with soft tissue grafting; use of biologic materials for soft or osseous tissue regeneration will not be considered in conjunction with guided tissue regenerations

    Documentation: Pretreatment diagnostic radiographic images (dated, properly oriented) demonstrating vertical bone defects and post-initial therapy 6-point periodontal charting (dated) within 12 months showing pocket depths of at least 5 mmradiographs and charting within 12 months; pockets >= 5 mm

    Required documentation must be current within 12 months

    Postoperative inclusion: Post-operative management is included for the immediate 3 months following surgery and for any surgical re-entry for 3 years (contract dependent)3 months and 3 years
    Coverage verification: For major (reconstructive) guided tissue regeneration procedures, verify the patient’s medical plan for coverage

    Contract-dependent prior authorization may be required

    Guided tissue regeneration is not considered a benefit when performed in conjunction with soft tissue grafting procedures. The policy specifically excludes combination procedures where guided tissue regeneration is performed together with soft tissue grafts, and such combined procedures are generally not eligible for coverage.

    The policy states that the use of biologic materials for soft or osseous tissue regeneration will not be considered in conjunction with guided tissue regenerations. When biologic materials are used for soft- or bone-regenerating purposes alongside guided tissue regeneration, those materials and their use are excluded from consideration as a covered benefit.

    Coding / Procedure Codes and Measurement Thresholds

    CDT codes (examples)CDT
    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
    Pocket depth — post-initial therapy 6-point periodontal charting threshold
    Threshold>= 5 mm (post‑initial therapy 6‑point periodontal charting)
    TimingCharting must be current (within 12 months)
    Charting typePost‑initial therapy 6‑point periodontal charting
    Recency of radiographs and charting requirement
    Required recencyRadiographs and post‑initial therapy 6‑point periodontal charting must be current within 12 months
    Radiograph specificationsDated, properly oriented, pretreatment diagnostic radiographic images demonstrating vertical bone defects

    Provider Actions and Documentation Requirements

    Prior Authorization

    Prior authorization is contract dependent

    Prior authorization may be required per contract. When prior authorization is required, submit documentation that demonstrates the indicated vertical or Class II furcation defects and includes the required pretreatment radiographs and post-initial therapy 6‑point periodontal charting (see documentation requirements).

    • Prior authorization is contract dependent.
    • Documentation submitted must show indicated defects and required radiographs/charting.
    Note

    Verify coverage and document medical necessity

    Provide documentation that supports medical necessity and verifies procedure appropriateness; check member’s medical plan for coverage for major reconstructive guided tissue regeneration and note that use with implants is contract dependent.

    • Confirm benefit coverage for major reconstructive procedures with the member's medical plan.
    • If performing guided tissue regeneration with dental implants, verify contract-specific coverage.

    Background

    Guided tissue regeneration is a surgical technique intended to achieve new bone, cementum and periodontal ligament attachment to teeth affected by periodontal disease. It is generally reserved for vertical, multi-walled or narrow defects with vertical bone loss and for appropriate Class II furcation defects, and is typically applied to periodontal and peri-implant defects (coverage for implants is contract dependent).

    The procedure requires documentation demonstrating the anatomic defect and need for regeneration, including dated, properly oriented pretreatment radiographs and post-initial therapy 6-point periodontal charting (see policy for required timeframes and threshold values). Postoperative management is included for the immediate 3 months following surgery, and any surgical re-entry is included for up to 3 years when contract terms apply.

    Definitions

    Definition of guided tissue regeneration
    DefinitionGuided tissue regeneration is a surgical procedure used to achieve new bone, cementum and periodontal ligament (PDL) attachment to a periodontally diseased tooth.
    Typical indicationsClass II furcation involvement and vertical defects (intrabony/infrabony)
    Adjunct useMay be used adjunctively with bone grafting
    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyGuided tissue regeneration (dental) coverage criteria
    Policy CodePolicy 04-209
    Change TypeNo material changes
    Effective DateJan 1, 2025
    Last ReviewOct 28, 2024
    Next Review DateJan 1, 2025
    Key ActionObtain and include current (within 12 months) dated radiographs and post-initial therapy 6-point periodontal charting showing pocket depths ≥5 mm; prior authorization may be required per contract.
    SourceLink
    On This Page
    Coverage CriteriaCoding / Procedure Codes and Measurement ThresholdsProvider Actions and Documentation RequirementsBackgroundDefinitions
    Documentation useBoth radiographs and charting must be included in documentation of necessity
    Documentation Required

    Required radiographs and periodontal charting

    Include current (within 12 months), dated, properly oriented pretreatment radiographic images demonstrating vertical bone defects and current (within 12 months), dated post‑initial therapy 6‑point periodontal charting showing pocket depths of at least 5 mm.

    • Pretreatment radiographs must be dated and properly oriented and demonstrate vertical bone defects.
    • Post‑initial therapy 6‑point periodontal charting must be dated within 12 months and show pockets ≥ 5 mm.
    Denial Risk

    Documentation- and indication-related denial risks

    Procedures may be denied if required documentation is not provided or if the indication is inappropriate (for example, procedures performed for extraction sites, performed with soft tissue grafting, or associated with endodontic or minor periradicular surgery).

    • Lack of current (within 12 months) radiographs or post‑initial therapy charting showing ≥ 5 mm pockets risks denial.
    • Procedures performed with soft tissue grafting, for extraction sites, or associated with endodontic/minor periradicular surgery are typically not covered and may be denied.