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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBCBS-WI Biological Materials Coverage Update | Ope…
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    ModifiedBlue Cross Blue Shield - WisconsinPolicy 03-401

    Biological Materials to Aid in Soft Tissue and Osseous Tissue Regeneration (Endodontic)

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    Defines coverage considerations and required documentation for use of biological materials (e.g., PRP, Emdogain, rhBMP, Gem-21S) to aid soft tissue and bone regeneration in dental/endodontic procedures for Blue Cross Blue Shield - Wisconsin members.

    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyBiological Materials to Aid in Soft Tissue and Osseous Tissue Regeneration (Endodontic)
    Policy CodePolicy 03-401
    Change TypeAdministrative review — no material clinical changes
    Effective Date
    Last ReviewOct 14, 2025
    Next Review Date
    Key ActionProvide current, dated (within 12 months) diagnostic-quality pretreatment periapical radiographs, 6-point periodontal charting showing ≥5mm pocket depths, and a letter of rationale specifying the biological material.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    3required documentation items listed
    >=5mm

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    minimum pocket depth specified
    6listed CDT procedure codes
    12radiograph recency (months)

    Coverage Criteria

    Coverage criteria

    Covered when ALL of the following documentation requirements are met:

    Documentation requirements: Current, dated (within 12 months) pretreatment periapical radiographic images that are of diagnostic quality.within 12 months

    Diagnostic-quality periapical radiographs required.

    Documentation requirements: Current, dated 6-point periodontal charting as described by the AAP and ADA indicating a minimum of 5 mm pocket depths.>= 5 mm

    Charting must be current and dated.

    Documentation requirements: Letter of rationale explaining the necessity of the regeneration procedure and specifying the biological material to be used (e.g., PRP, Emdogain, rhBMP, Gem-21S).

    May be requested to support medical necessity.

    The use of biological materials will not be considered for coverage when they are applied in conjunction with other regenerative procedures or materials. Examples include use with soft tissue grafting, bone grafts, guided tissue regeneration, ridge augmentation, periradicular surgery, when placed within extraction sites, or when used together with other regenerative materials. These situations are excluded from consideration regardless of specific group plan coverage.

    Coding and Measurement Requirements

    CDT codes listedmixed
    D3428Bone Graft in conjunction with periradicular surgery, single site.
    D3429Bone Graft in conjunction with periradicular surgery, each additional site.
    D3431Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery.
    D3432Guided Tissue Regeneration, resorbable barrier, per site, in conjunction with periradicular surgery.
    D4265Biological material to aid in soft and osseous tissue regeneration, per site.
    D7921Collection and application of autologous blood concentrate product
    inv-04: Minimum pocket depth
    Minimum pocket depth>= 5 mm (documented on current, dated 6-point periodontal charting per AAP/ADA)
    Charting standard6-point periodontal charting as described by the American Academy of Periodontology (AAP) and American Dental Association (ADA)
    Dating requirementCharting must be current and dated (within 12 months)
    inv-05: Radiograph recency
    Radiograph recency requirementCurrent, dated pretreatment periapical radiographic images within 12 months (diagnostic quality)
    Image typePeriapical radiographic images of diagnostic quality

    Provider Actions and Documentation Requirements

    Prior Authorization

    Prior authorization and coding verification

    Verify member contract benefits and prior authorization requirements before performing or billing for biological materials; the CDT codes listed in this policy are provided for informational purposes and do not guarantee coverage.

    • Check the member’s contract at time of service to determine coverage or need for prior authorization.
    • CDT codes in this document are informational only and inclusion does not imply coverage or reimbursement.
    Note

    Action: Confirm member coverage and prepare documentation

    Confirm necessity and coverage on an individual-member basis and be prepared to provide clinical justification; coverage is considered only when required documentation is submitted.

    • Ensure all required documentation (radiographs, periodontal charting, letter of rationale) is available when requesting coverage or prior authorization.
    • Be aware that use of biological materials in certain concurrent procedures may not be considered (see denial risk block).

    Background

    Tissue engineering and regenerative therapy seek to restore or replace damaged periodontal and osseous tissues by using biological substitutes rather than relying solely on traditional grafts. Regenerative approaches described in this policy may be applied to periodontal defects of natural teeth and dental implants and include products such as enamel matrix derivatives, platelet concentrates (e.g., PRP), and recombinant growth factors (e.g., rhBMP, Gem-21S). The goal is to regenerate tissue structure and function to improve clinical outcomes.

    Definitions

    inv-11: Tissue engineering / regenerative therapy definition
    DefinitionProcess by which damaged tissues are regenerated using biological substitutes that restore, maintain, or improve tissue function.
    Scope of applicationUsed to regenerate periodontal and osseous tissues for defects of natural teeth and dental implants
    Alternative to graftsAn approach that regenerates tissues rather than relying on autografts or allografts
    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyBiological Materials to Aid in Soft Tissue and Osseous Tissue Regeneration (Endodontic)
    Policy CodePolicy 03-401
    Change TypeAdministrative review — no material clinical changes
    Effective Date
    Last ReviewOct 14, 2025
    Next Review Date
    Key ActionProvide current, dated (within 12 months) diagnostic-quality pretreatment periapical radiographs, 6-point periodontal charting showing ≥5mm pocket depths, and a letter of rationale specifying the biological material.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Measurement RequirementsProvider Actions and Documentation RequirementsBackgroundDefinitions
    Dating requirementRadiographs must be current and dated (within 12 months)
    Documentation Required

    Required documentation

    Provide the following current, dated documentation to support coverage consideration for biological materials:

    • Pretreatment periapical radiographic images of diagnostic quality dated within the prior 12 months.
    • Current, dated 6-point periodontal charting as described by the AAP and ADA showing minimum 5 mm pocket depths.
    • Letter of rationale explaining the necessity of the regeneration procedure and specifying the biological material to be used (e.g., PRP, Emdogain, rhBMP, Gem-21S).
    Denial Risk

    Denial risk: concurrent procedures/materials

    Coverage may be denied when biological materials are used concurrently with certain other procedures or materials.

    • Use of biological materials may not be considered when used in conjunction with soft tissue grafting, bone grafts, guided tissue regeneration, ridge augmentation, periradicular surgery, placed within extraction sites, or when utilized with other regenerative materials regardless of specific group plan coverage.