CurrentBlue Cross Blue Shield - MainePolicy Guidelines #: 04-209

Guided Tissue Regeneration

Defines clinical indications, documentation requirements, limitations, and coding references for coverage review of guided tissue regeneration dental procedures under the plan; coverage may be group-contract dependent.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyGuided Tissue Regeneration

Policy CodePolicy Guidelines #: 04-209

Change TypeClarified (annual review)

Effective DateJan 1, 2023

Next Review Date

Key ActionInclude current (within 12 months), dated, post-initial therapy 6-point periodontal charting demonstrating minimum 5 mm pocket depths and pretreatment radiographs showing vertical bone defects; verify member benefits and check the patient's medical plan for major reconstructive procedures.

SourceLink

POLICY UPDATE CHANGES

Annual review on 10/28/2022; policy published effective 01/01/2023.

3Primary Indications Listed

3Explicit Exclusions/Not Covered Scenarios

3Key Documentation Requirements

Coverage Summary

Anthem coverage guidance for Guided Tissue Regeneration (dental). This policy defines clinical indications, documentation requirements, limitations, and coding references for review of guided tissue regeneration procedures. Coverage determination is group-contract dependent — the plan reviews procedures against generally accepted standards of dental care and the member's contract to determine if a requested service is a covered benefit. Policy status: CURRENT; publish/effective date: 01/01/2023; last review: 10/28/2022.

Medically/Dentally Necessary Criteria

Medically/Dentally Necessary Criteria for Guided Tissue Regeneration

Guided tissue regeneration may be appropriate when ALL of the following are met:

ALL of the following

ONE OF
- Class II furcation involvement
- Vertical defects (intrabony and infrabony)
- Vertical, multi-walled or narrow defects with areas of vertical bone loss or class II furcation defects
Use in conjunction with bone grafting
Guided tissue regeneration may be appropriate when used in conjunction with bone grafting
Current periodontal chartingpocket depths of a minimum of 5 mm
Charting must be current within 12 months and be dated, post initial therapy, 6-point periodontal charting
Radiographic documentation
Current (within 12 months), dated, properly oriented, pretreatment radiographic images demonstrating vertical bone defects must be included
Procedure limited to periodontal and peri-implant defects
Guided tissue regeneration procedures are generally limited to treatment of periodontal and peri-implant defects (dependent upon group contract)
Check medical plan for major reconstructive procedures
For major guided tissue regeneration (reconstructive) procedures, the patient's medical plan should be checked for coverage

Not Covered / Exclusions

Situations Not Covered / Exclusions

Guided tissue regeneration is not considered a covered benefit when ANY of the following apply:

ANY of the following

Procedures associated with endodontic therapies or with minor periradicular surgery
Typically not a covered benefit as bone heals by secondary intention
When performed in conjunction with soft tissue grafting procedures
Not considered for benefits
Use of biologic materials for soft or osseous tissue regeneration in conjunction with guided tissue regeneration
Will not be considered

Provider Actions & Documentation Requirements

Documentation Required

Provide current periodontal charting

Include current (within 12 months), dated, post-initial therapy 6-point periodontal charting demonstrating minimum 5 mm pocket depths.

Minimum 5 mm pocket depths

Documentation Required

Provide pretreatment radiographs

Include current (within 12 months), dated, properly oriented, pretreatment radiographic images demonstrating vertical bone defects.

within 12 months, properly oriented, dated

Prior Authorization

Benefit may be group-contract dependent

Determine member coverage by checking the member's dental contract and, for major reconstructive procedures, check the patient's medical plan for coverage.

Check dental contract
Check medical plan for major reconstructive procedures

Billing Rule

CDT codes informational only

The listed CDT codes are provided for informational purposes; inclusion does not guarantee member coverage or provider reimbursement—verify member benefits at time of service.

D3432
D4266
D4267

Background & Evidence

Guided tissue regeneration is a surgical procedure used to achieve new bone, cementum and periodontal ligament attachment for periodontally diseased teeth. The policy evaluates these procedures against generally accepted standards of dental care and group contract benefits to determine whether the procedure is dentally necessary and a covered benefit. Indications addressed include Class II furcation involvement and vertical defects (intrabony and infrabony), and use in conjunction with bone grafting; the procedure is generally confined to vertical, multi-walled or narrow defects with areas of vertical bone loss or Class II furcation defects.

Referenced guidance includes the American Academy of Periodontology Parameters of Care and related literature (references listed).

Dental review: dental services provided in accordance with generally accepted standards of dental practice that a Dentist, exercising prudent clinical judgment, provides to evaluate, diagnose or treat a dental injury or disease; services that are effective for the patient's condition, not primarily for convenience, not cosmetic, and not more costly than alternatives.

Revision History

2022-10-28clarified

Annual review; policy published effective 01/01/2023

2023-01-01publishLatest

Policy published effective date

2020-05-06revision

Initial policy version (listed in revision history)

2020-12-04annual review

Annual review (revision history)

2021-10-30annual review