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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBCBS Wisconsin Periodontal Bone Grafting Coverage …
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    CurrentBlue Cross Blue Shield - WisconsinPolicy 04-201

    Periodontal Bone Grafting — Coverage Criteria

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    Defines coverage criteria, required documentation, and coding for periodontal bone grafting procedures for Blue Cross Blue Shield - Wisconsin members.

    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyPeriodontal Bone Grafting — Coverage Criteria
    Policy CodePolicy 04-201
    Change TypeCriteria addedcode deleted
    Effective DateJan 1, 2025
    Last ReviewAug 29, 2024
    Next Review Date
    Key ActionSubmit prior authorization with recent dated radiographs, a letter of rationale, a current periodontal chart (within 12 months), and relevant clinical documentation.
    SourceLink
    POLICY UPDATE CHANGES

    Criteria #13 and #14 added; Deleted code D6104.

    Minor editorial refinements to description, clinical indications, criteria and reference; intent unchanged.

    14clinical criteria items listed
    8

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    CDT procedure codes
    12 monthsradiograph/chart recency
    5 mmminimum pocket depth

    Coverage Criteria

    inv-01: Covered when ALL of the following are met

    Bone grafting for periodontal/peri-implant defects is covered when all specified clinical and documentation criteria are satisfied:

    Anatomic/clinical defect: Defect is a vertical, multi-walled, narrow defect or a class II furcation defect; wide horizontal interproximal defects are not favorable for grafting.

    Criteria 1-2

    Appropriate timing: Procedure is for periodontal/peri-implant defects (group contract dependent) and completion of initial periodontal therapy (e.g., scaling and root planing) with a minimum four-week healing interval prior to surgical treatment has occurred.

    Criteria 3 and 13

    Documentation: Submission includes diagnostic-quality, properly oriented, current (within 12 months), dated pretreatment radiographic images demonstrating vertical bone defects; current (within 12 months), dated post-initial therapy 6-point periodontal charting with minimum pocket depth of >= 5 mm; a letter of rationale explaining necessity and relationship to other services; recent patient health history; and other supporting items such as CBCT, photos, narrative and chart notes as needed.radiographs/chart within 12 months; pocket depth >= 5 mm

    Criteria 5,6,12,14

    Material and adjuncts: Use of biologic materials for soft or osseous tissue regeneration may not be benefitted in conjunction with bone grafts (contract dependent); bone graft procedures include postoperative management for the immediate three months following surgery and for any surgical re-entry for three years (group contract dependent).

    Criteria 7 and 8

    inv-02: Not covered / Limited utility — 1 top-level node

    Common Not Benefitted Situations: Bone grafts associated with endodontic therapies or minor periradicular surgery may not be benefitted because bone commonly heals by secondary intention; bone grafts performed in conjunction with soft tissue grafting procedures are not considered for benefits.

    Criteria 4 and 10

    Adjunctive procedures that are related to a primary non-covered procedure are not covered. This includes, but is not limited to, bone grafts and use of membranes when the primary procedure itself is not a covered benefit even if the adjunctive procedure is otherwise covered by the plan.

    Providers must submit the full clinical documentation package described elsewhere in this policy when requesting benefit determination; failure to document necessity and the relationship to other services may result in denial.

    Bone grafting is generally indicated for vertical, multi-walled, narrow defects and for Class II furcation defects. Wide horizontal interproximal defects are explicitly noted to have limited positive outcomes with grafting techniques and therefore are not favorable candidates for bone grafting.

    Bone graft procedures associated with endodontic therapies or minor periradicular surgery generally are not benefited because bone commonly heals by secondary intention. Additionally, bone grafts performed in conjunction with soft tissue grafting procedures are not considered for benefits.

    Coding and Clinical Thresholds

    Covered CDT Codes (as listed)CDTCovered
    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
    ICD-10 DiagnosesICD-10
    No codes listed
    inv-07: Minimum pocket depth after initial therapy
    Minimum pocket depthCurrent (within 12 months) post-initial therapy 6-point periodontal charting indicating minimum pocket depth of 5 mm
    Timing relative to initial therapyCharting must be post-initial therapy after completion of scaling and root planing with minimum four-week healing interval before surgery
    Charting standard6-point periodontal charting (detailed pocket measurements) is required and must be dated within 12 months
    inv-08: Recency for radiographs and periodontal charting
    Radiographs recencyDiagnostic-quality, properly oriented, current pretreatment radiographic images demonstrating vertical bone defects must be within 12 months and dated
    Periodontal chart recency

    Provider Actions and Documentation Requirements

    Prior Authorization

    Prior authorization required for periodontal bone grafting codes

    Prior authorization must be obtained for the listed periodontal bone grafting CDT codes and requires submission of the full clinical documentation package to determine benefit for these codes.

    • Applicable CDT codes: D4263, D4264, D4265, D4266, D4267, D4286, D6103, D7295
    • Submit the complete documentation package (radiographs, letter of rationale, recent health history, current periodontal chart) with the prior authorization request
    Step Therapy

    Initial therapy completion and required healing interval before surgery

    Providers must complete initial periodontal therapy (for example, scaling and root planing) and allow a minimum four-week healing interval before performing surgical bone grafting to permit assessment of non‑surgical therapy success.

    • Allow at least four weeks between completion of initial therapy and any surgical treatment

    Background

    Periodontal bone grafting is a surgical procedure performed on retained natural teeth to restore or regenerate alveolar bone lost from periodontal disease by placing graft material (autogenous, allograft, or alloplastic) as a scaffold for new bone growth. It is intended to replace missing bone of the maxilla or mandible resulting from periodontitis and is most appropriate for narrow, multi-walled vertical defects and certain furcation defects.

    Coverage is focused on procedures aimed at regenerating bone for periodontal or peri-implant defects and is contingent on meeting clinical criteria and documentation requirements, including diagnostic-quality, properly oriented, current (within 12 months) dated radiographs, a dated periodontal chart showing a minimum pocket depth of 5 mm after initial therapy, a letter of rationale, and recent patient health history.

    Prior to considering surgical bone grafting, completion of initial periodontal therapy (for example, scaling and root planing) with a minimum healing interval of four weeks is required to assess the response to non-surgical treatment.

    Definitions

    inv-14: Class II furcation defect definition
    DefinitionLoss of bone between the roots (typically of molar teeth) where bone grafting may be appropriate
    Clinical relevanceClass II furcation defects are one of the anatomic situations for which bone graft replacement is generally confined (vertical, multi-walled, narrow defects or class II furcations)
    Typical locationMost commonly involves molar teeth in the maxilla or mandible where roots diverge
    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyPeriodontal Bone Grafting — Coverage Criteria
    Policy CodePolicy 04-201
    Change TypeCriteria addedcode deleted
    Effective DateJan 1, 2025
    Last ReviewAug 29, 2024
    Next Review Date
    Key ActionSubmit prior authorization with recent dated radiographs, a letter of rationale, a current periodontal chart (within 12 months), and relevant clinical documentation.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Clinical ThresholdsProvider Actions and Documentation RequirementsBackgroundDefinitions
    Current (within 12 months), dated, post-initial therapy 6-point periodontal charting is required
    Additional imaging and documentationCBCT, photos, narrative, letter of rationale, recent patient health history, and chart notes may be required and must be current (within 12 months) as applicable
  1. Document completion of initial therapy in the clinical record submitted for review
    2. Documentation Required

    Required clinical documentation (radiographs, charting, rationale, health history)

    Submit recent, dated, diagnostic-quality, properly oriented pretreatment radiographic images (within 12 months), a dated post‑initial therapy 6‑point periodontal chart (within 12 months) showing minimum pocket depth of 5 mm, a letter of rationale explaining necessity and relation to other services, and a recent patient health history; CBCT, photos, narrative, and chart notes may also be required for benefit determination.

    • Pretreatment radiographs: diagnostic quality, properly oriented, current (within 12 months), dated
    • Post‑initial therapy 6‑point periodontal chart: current (within 12 months), dated, minimum pocket depth ≥ 5 mm
    • Letter of rationale stating necessity of bone graft and whether it is related to another service
    • Recent patient health history and any relevant CBCT, photos, narrative, and chart notes
    Denial Risk

    Documentation completeness and relation to non‑covered primary service — denial risk

    Failure to provide the required documentation or when the bone graft is related to a non‑covered primary procedure may result in denial; adjunctive procedures related to a non‑covered primary service (including bone grafts and membranes) are not covered.

    • If the primary procedure is not a covered service, all related adjunctive procedures (including bone grafts and use of membranes) are not covered and may be denied
    • Missing recent dated radiographs, letter of rationale, recent health history, or current periodontal chart (within 12 months) may lead to denial of the request