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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield WI biologic materials Cover…
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    CurrentBlue Cross Blue Shield - WisconsinPolicy 04-203

    Biological Materials to Aid in Soft and Osseous Tissue Regeneration

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    Policy governing use of biologic materials to aid soft tissue and bone regeneration in dental practice (periodontal defects of natural teeth and implants); applies to providers and claims when member contract allows coverage.

    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyBiological Materials to Aid in Soft and Osseous Tissue Regeneration
    Policy CodePolicy 04-203
    Change TypeNo material changes
    Effective DateJan 1, 2026
    Last ReviewOct 16, 2025
    Next Review Date
    Key ActionDocument current (within 12 months) diagnostic-quality pretreatment periapical radiographs and dated post-initial therapy 6-point periodontal charting showing minimum 5 mm pocket depths.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    5mmminimum pocket depth
    12 mocharting/radiograph age
    D3431,D4265,D4266

    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.

    example CDT codes
    04-203policy id

    Coverage criteria

    Coverage criteria

    Covered when ALL of the following are documented and coverage is allowed by the member's specific group contract:

    Documentation and clinical thresholds: 1) Current (within 12 months), diagnostic-quality, pretreatment periapical radiographic images. 2) Current (within 12 months), dated, post initial therapy 6-point periodontal charting indicating a minimum of 5 mm pocket depths. 3) Rationale supporting the regeneration procedure and the type of material being used may be requested (examples: PRP, Emdogain, rhBMP, GEM 21S).see node text

    Coverage subject to member contract benefits

    The use of biological materials may not be considered for coverage when they are applied in combination with other surgical or regenerative procedures. Specifically, coverage may be denied if biologic materials are used in conjunction with soft tissue grafting, bone grafts, guided tissue regeneration, ridge augmentation, periradicular surgery, if they are placed within extraction sites, or if they are utilized with other regenerative materials.

    Coding and billing notes

    Included CDT codes (informational)CDT
    D3431
    D4265Biologic materials to aid in soft and osseous tissue regeneration, per site
    D4266Guided tissue regeneration - resorbable barrier per site
    inv-04: Minimum pocket depth
    Minimum pocket depth (periodontal charting)>= 5 mm
    Required periodontal charting timeframeCurrent, within 12 months
    Charting typeDated, post initial therapy 6‑point periodontal charting

    Provider actions and requirements

    Note

    Check member contract for coverage/prior authorization (D3431, D4265, D4266)

    Confirm member contract benefits and prior authorization requirements for procedures involving biologic materials; the listed CDT codes are provided for informational purposes only.

    • Referenced CDT codes include D3431, D4265, D4266 — inclusion does not guarantee coverage or payment.
    • Refer to the member's contract benefits in effect at the time of service to determine coverage and any prior authorization requirements.
    Prior Authorization

    Verify contract-specific coverage and meet policy documentation requirements

    Coverage for biologic materials is allowed only when the documentation and clinical thresholds in the policy are met and coverage is permitted by the member's specific group contract.

    • All coverage is subject to the member's specific group contract benefits.
    • Documentation and clinical thresholds required are detailed in the policy criteria (radiographs, periodontal charting, rationale).

    Background

    Tissue engineering and regenerative medicine seek to restore or replace damaged tissues using biological substitutes rather than traditional grafts. In dentistry, these adjunctive biologic materials are used to promote regeneration in periodontal defects of natural teeth and around dental implants; examples of materials that may be considered include platelet rich plasma (PRP), Emdogain®, recombinant human bone morphogenic protein (rhBMP), and GEM 21S®.

    Definitions

    inv-10: Tissue engineering / regenerative medicine definition
    TermTissue engineering / regenerative medicine
    DefinitionProcess by which damaged tissues are regenerated by developing biological substitutes that restore, maintain, or improve tissue function.
    Dental applicationAdjunctive regenerative therapy using biological materials for periodontal defects of natural teeth and dental implants.
    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyBiological Materials to Aid in Soft and Osseous Tissue Regeneration
    Policy CodePolicy 04-203
    Change TypeNo material changes
    Effective DateJan 1, 2026
    Last ReviewOct 16, 2025
    Next Review Date
    Key ActionDocument current (within 12 months) diagnostic-quality pretreatment periapical radiographs and dated post-initial therapy 6-point periodontal charting showing minimum 5 mm pocket depths.
    SourceLink
    On This Page
    Coverage criteriaCoding and billing notesProvider actions and requirementsBackgroundDefinitions
    Documentation Required

    Required documentation: radiographs and periodontal charting (within 12 months)

    Document and retain current diagnostic-quality pretreatment periapical radiographs and a dated, post initial therapy 6-point periodontal charting showing the minimum pocket depths within 12 months of the procedure.

    • Pretreatment periapical radiographic images must be current (within 12 months) and diagnostic quality.
    • Post initial therapy 6-point periodontal charting must be current (within 12 months), dated, and indicate minimum 5 mm pocket depths.
    • Rationale for the procedure and specific material used (e.g., PRP, Emdogain®, rhBMP, GEM 21S®) may be requested.
    Denial Risk

    Denial risk: exclusion when combined with grafts, other regeneration procedures, or extraction sites

    Biologic materials may not be considered for coverage when used with certain procedures or placed in specific situations; billing or authorization may be denied if these conditions apply.

    • Not considered when used in conjunction with soft tissue grafting, bone grafts, guided tissue regeneration, ridge augmentation, or periradicular surgery.
    • Not considered when placed within extraction sites or when utilized with other regenerative materials.