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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield - Maine Periodontal Bone Gr…
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    CurrentBlue Cross Blue Shield - MainePolicy 04-201

    Periodontal Bone Grafting — Coverage Criteria

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    Covers clinical indications, documentation requirements, coding, and coverage criteria for periodontal bone grafting procedures for retained natural teeth and peri-implant defects under the payer's dental policy.

    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyPeriodontal Bone Grafting — Coverage Criteria
    Policy CodePolicy 04-201
    Change TypeRoutine review — no material changes
    Effective DateJan 1, 2026
    Last ReviewOct 14, 2025
    Next Review DateJan 1, 2026
    Key ActionObtain prior authorization with dated radiographs, a letter of rationale, recent health history, and a current 6‑point periodontal chart (within 12 months).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    14listed criteria items
    9CDT codes provided
    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/chart recency
    5 mmminimum pocket depth

    Coverage Criteria

    Medically necessary criteria

    Covered when ALL of the following are met:

    ALL of the following

    • Defect type: Defect is vertical, multi-walled, narrow or class II furcation

      Generally confined to these defect types

    • Defect not wide horizontal: Wide horizontal interproximal defects are not favorable for grafting

      Limited positive outcomes

    • Purpose: For treatment of periodontal or peri-implant defects (group contract dependent)

      Dependent on group contract for peri-implant

    • Radiographic documentation: Pretreatment diagnostic quality, properly oriented, dated radiographs demonstrating vertical bone defectswithin 12 months

      Required

    • Periodontal charting: Post initial therapy 6-point periodontal charting indicating minimum pocket depth of 5 mmwithin 12 months

      Required

    • Initial therapy completed: Completion of initial periodontal therapy (e.g., scaling and root planing) with a minimum four-week interval prior to surgical treatment

      Required to allow healing and assessment

    • AAP/ADA diagnosis: Periodontal diagnosis including staging and grading per current AAP and ADA guidelines

      Required

    • Adjunctive procedures relation: If primary procedure is non-covered, related adjunctive procedures including bone grafts are not a covered benefit

      May cause denial

    Bone graft procedures performed in direct conjunction with soft tissue grafting are not considered a covered benefit. This exclusion reflects the policy position that bone grafts submitted as part of concurrent soft tissue grafting procedures will not be reimbursed under the payer’s dental policy.

    Bone grafting that is associated with endodontic therapy or minor periradicular surgery may be not benefitted because such sites typically heal by secondary intention. When bone grafts are submitted for procedures whose primary service is endodontic or minor periradicular in nature, benefit determination may result in non-coverage.

    Bone grafts submitted for wide horizontal interproximal defects are considered to have limited benefit and are not supported as medically necessary, reflecting generally poor positive outcomes for grafting in these defect types.

    Coding and Clinical Thresholds

    CDT codesCDT
    D4263Bone replacement graft - retained natural tooth- first site in quadrant
    D4264Bone replacement graft - retained natural tooth- each additional site in quadrant
    D4265Biologic materials to aid in soft and osseous tissue regeneration, per site
    D4266Guided tissue regeneration - resorbable barrier, per site
    D4267Guided tissue regeneration - non-resorbable barrier, per site
    D4286Removal of non-resorbable barrier
    D6103Bone graft for repair of peri-implant defect - does not include flap entry and closure
    D7295Harvest of bone for use in autogenous grafting procedure
    D7921Collection and application of autologous blood concentrate product
    Minimum pocket depth — inv-06
    Threshold>= 5 mm on 6-point periodontal charting after completion of initial therapy
    TimingCharting must be current (within 12 months) and dated
    ContextPost-initial therapy charting required to assess non-surgical treatment response (minimum four-week healing interval)
    Recency of radiographs and periodontal chart — inv-07
    Maximum ageRadiographs and periodontal chart must be current within 12 months
    Required imagingPretreatment, diagnostic-quality, properly oriented, dated radiographs demonstrating vertical bone defects

    Provider Actions and Documentation

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for bone grafting procedures. Submit all required documentation listed below with the prior authorization request; missing or incomplete documentation may result in denial or delay.

    • Affected CDT/CPT codes: submit under the applicable procedure code(s).
    • Submit prior authorization before scheduling elective bone graft procedures when required by the member’s plan.
    Documentation Required

    Required Documentation for Submission

    Submit the following documentation with the prior authorization request. All items must be current (dated) and clearly legible.

    • Dated, diagnostic-quality radiographs (periapical and/or bitewing) or current CBCT demonstrating the defect — must be properly oriented and within 12 months.
    • A clear letter of medical/dental rationale explaining the necessity of the bone graft and whether it is related to another service (e.g., osseous surgery, implant, endodontic therapy).

    Background

    Periodontal bone grafting is a surgical intervention intended to restore or regenerate bone lost from periodontal disease by placing graft material into an osseous defect. It is generally targeted to vertical, multi-walled, narrow defects or class II furcation defects and is limited to treatment of periodontal or peri-implant defects depending on group contract. Policy requirements for coverage include pretreatment, diagnostic-quality, properly oriented, dated radiographs (current within 12 months), and post-initial therapy 6-point periodontal charting demonstrating a minimum pocket depth of 5 mm. Completion of initial periodontal therapy with a minimum four-week healing interval prior to surgical grafting is required, and additional documentation such as CBCT, photographs, narrative rationale, recent health history, and chart notes may be requested for benefit determination.

    Definitions

    Bone graft materials — inv-13
    AutogenousGraft material obtained from the patient (autograft)
    AllograftGraft material obtained from a donor (allograft)
    AlloplasticSynthetic graft material serving as a scaffold to promote bone regeneration
    Appropriate defect types — inv-14
    Appropriate defect typesVertical, multi-walled, narrow defects or class II furcation defects
    Not favorableWide horizontal interproximal defects demonstrate limited positive outcomes and are generally not supported
    Scope
    Policy Summary
    PayerBlue Cross Blue Shield - Maine
    PolicyPeriodontal Bone Grafting — Coverage Criteria
    Policy CodePolicy 04-201
    Change TypeRoutine review — no material changes
    Effective DateJan 1, 2026
    Last ReviewOct 14, 2025
    Next Review DateJan 1, 2026
    Key ActionObtain prior authorization with dated radiographs, a letter of rationale, recent health history, and a current 6‑point periodontal chart (within 12 months).
    SourceLink
    On This Page
    Coverage CriteriaCoding and Clinical ThresholdsProvider Actions and DocumentationBackgroundDefinitions
    Documentation noteCBCT, photos, narrative, letter of rationale, recent patient health history, and chart notes may be considered for benefit determination
  1. Recent patient health history and pertinent medical status documentation.
  2. Dated periodontal charting (6-point) post-initial therapy showing minimum pocket depth of 5 mm where applicable; charting must be ≤12 months old and follow ADA reporting guidelines.
  3. Documentation of completion of initial periodontal therapy (e.g., scaling and root planing) with a minimum healing interval (see prior-auth/initial therapy callout).
  4. Photographs and narrative operative notes when available to better demonstrate the defect and treatment plan.
    5. Denial Risk

    Documentation-Related Denial Triggers

    Incomplete documentation is a common reason for denial. Ensure the prior authorization request includes all required items to avoid denial or delay.

    • Missing or non-diagnostic radiographs or CBCT images (not current, not properly oriented, or not demonstrating the defect).
    • Absence of a dated letter of rationale explaining medical necessity and relationship to other services.
    • Missing or outdated patient health history.
    • Missing, incomplete, or expired periodontal charting (must be a current 6-point chart ≤12 months).
    • Failure to document completion of initial periodontal therapy with the required healing interval prior to surgical bone grafting when indicated.
    Typically limited to treatment of periodontal and peri-implant defects (group contract dependent)