ModifiedBlue Cross Blue Shield - WisconsinPolicy 04-203

Biological Materials to Aid in Soft and Osseous Tissue Regeneration

Policy governing use and documentation requirements for biologic materials used to aid soft tissue and bone regeneration in dental care when covered by specific group contracts; applies to providers submitting claims to the plan.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBiological Materials to Aid in Soft and Osseous Tissue Regeneration

Policy CodePolicy 04-203

Change TypeRevised

Effective Date01/01/2022

Next Review Date

Key ActionDocument pretreatment diagnostic periapical radiographs (≤12 months) and current 6-point periodontal charting showing ≥5 mm pocket depths when submitting for biologic material coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D4265, D4266CDT codes referenced

5mmmin pocket depth

12momax radiograph age

6-pointperiodontal charting

Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBiological Materials to Aid in Soft and Osseous Tissue Regeneration

Policy CodePolicy 04-203

Change TypeRevised

Effective Date01/01/2022

Next Review Date

Key ActionDocument pretreatment diagnostic periapical radiographs (≤12 months) and current 6-point periodontal charting showing ≥5 mm pocket depths when submitting for biologic material coverage.

SourceLink

On This Page

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Documentation and contract conditions: 1) Pretreatment periapical radiographic images that are of diagnostic quality, properly oriented, identified, and dated within 12 months; 2) Current, dated 6-point periodontal charting indicating a minimum of 5 mm pocket depths; 3) A letter of rationale explaining the necessity of the regeneration procedure and the type of biologic material used may be requested (examples: PRP, Emdogain, rhBMP, Gem-21S).

Coverage is subject to the member's specific group contract terms and general dental necessity criteria.

The policy clarifies situations in which the plan may not consider the use of biologic materials for regeneration. Specifically, biologic 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. Providers should ensure the requested service is consistent with the member’s group contract and the documented indication before submitting claims or prior authorization requests.

Coding and Measurement Requirements

Included CDT Codes (informational)CPT

D4265	Biologic materials to aid in soft and osseous tissue regeneration, per site
D4266	Guided tissue regeneration - resorbable barrier per site

Included CDT Codes (informational)CPT

D4265	Biologic materials to aid in soft and osseous tissue regeneration, per site
D4266	Guided tissue regeneration - resorbable barrier per site

Periodontal pocket depth — minimum threshold

Minimum periodontal pocket depthMinimum 5 mm pocket depth on current, dated 6-point periodontal charting

Charting type requiredCurrent, dated 6-point periodontal charting

Documentation purposeUsed to demonstrate clinical indication for biologic materials when group contract allows coverage

Age of diagnostic periapical radiograph — maximum accepted age

Maximum accepted agePretreatment periapical radiographic images must be dated within 12 months

Image qualityRadiographs must be of diagnostic quality, properly oriented, and identified

UseRequired as part of documentation for coverage when group contract applies

Provider Documentation and Action Requirements

Documentation Required

Required documentation

When coverage is governed by a specific group contract, the following documentation must be provided to support use of biologic materials.

Pretreatment periapical radiographs: diagnostic-quality, properly oriented, identified and dated, current within 12 months.
Current, dated 6‑point periodontal charting showing a minimum 5 mm pocket depth.
Letter of rationale describing medical necessity for the regenerative procedure and specifying the biologic material (examples: platelet rich plasma (PRP), Emdogain, recombinant human bone morphogenic protein (rhBMP), Gem-21S).
All records must be dated and clearly linked to the treatment episode.

Note

Provider actions and record retention

Provide the requested records at the time of claim submission or upon request. Failure to supply complete, dated diagnostic records may result in non‑consideration or denial of benefits under the group contract.

Include provider contact information and a brief explanatory note if the requested records are not part of the original claim submission.
Retain and make available intraoral images, radiographs, periodontal charting and the letter of rationale for audit/review.
Requests for additional information should be fulfilled promptly to avoid delayed processing.

Denial Risk

Situations that can trigger non‑consideration or denial

Use of biologic materials may be excluded or not considered in certain situations; document justification when any of the following apply to avoid denial.

Concomitant use with soft tissue grafting.
Use in combination with bone grafts or guided tissue regeneration.
Placement within extraction sites.
Utilization during periradicular (endodontic) surgery.
Concurrent use with other regenerative materials regardless of specific group plan coverage.

Background

Tissue engineering and regenerative medicine in dentistry focus on restoring damaged soft and osseous tissues using biologic substitutes rather than traditional grafting alone. Adjunctive biologic therapies (for example, platelet rich plasma, Emdogain, recombinant human bone morphogenic protein) may be used to support regeneration of periodontal defects around natural teeth and dental implants, but their use must meet the policy’s documentation and contract requirements to be considered for coverage.

Definitions

Tissue engineering / regenerative medicine definition

DefinitionTissue engineering or regenerative medicine: a process by which damaged tissues are regenerated by developing biological substitutes that restore, maintain or improve tissue function.

Dental applicationIn dentistry, adjunctive regenerative therapy using biological materials can treat periodontal defects of natural teeth and dental implants.

Approach vs graftingAims to regenerate damaged tissues rather than using grafts (autografts, allografts).