CurrentBlue Cross Blue Shield - WisconsinPolicy 04-201

Bone Grafts for Surgical Services (Periodontal)

Defines clinical appropriateness, documentation, and coding expectations for bone grafting and bone graft substitutes used with periodontal and peri-implant procedures for members covered by the plan.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBone Grafts for Surgical Services (Periodontal)

Policy CodePolicy 04-201

Change TypeNo material clinical or coverage changes

Effective DateJan 1, 2022

Next Review Date

Key ActionSubmit diagnostic-quality dated radiographs and a current periodontal chart (within 12 months) with requests for bone grafting procedures.

SourceLink

≥5 mmminimum pocket depth required in periodontal charting

12 monthsmaximum age of required radiographs and periodontal charting

3 monthspost-operative management period included with graft procedure

3 yearssurgical re-entry follow-up period (group contract dependent)

CDT listedspecific procedure codes referenced

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Medically Appropriate Indications

Bone grafting for periodontal/peri-implant defects is considered when ALL of the following are met:

Defect type: Defect is vertical, multi-walled, narrow or class II furcation; broad horizontal interproximal defects are generally not responsive to grafting.

Based on clinical indications (see clinical context).

Documentation: Diagnostic-quality, dated (within 12 months) radiographic images demonstrating vertical bone defects and a current (within 12 months) 6-point periodontal chart showing minimum pocket depth of 5 mm are submitted.Radiographs and chart ≤12 months; pocket depth ≥5 mm

CBCT, photos, narrative and chart notes may be required; include letter of rationale and recent patient health history.

Service relationship: Primary procedure must be a covered service; adjunctive procedures related to a non-covered primary procedure (including membranes) are not covered.

When the primary procedure is not covered, related adjunctive procedures are not a benefit.

Procedure type: Grafting limited to treatment of periodontal and peri-implant defects; routine placement into extraction sites and grafting performed in conjunction with soft tissue grafting are generally not considered benefits.

Grafts associated with endodontic therapies or minor periradicular surgery may not be benefitted.

Bone grafts performed in conjunction with soft tissue grafting procedures are not considered for benefits. Additionally, routine placement of bone grafts into extraction sites may not be necessary for complete and adequate healing and therefore are generally not considered a benefit. When bone grafting is related to a non-covered primary procedure, all related adjunctive procedures (including use of membranes) are also not covered even if those adjunctive procedures would be covered in other contexts.

Broad horizontal interproximal defects have been reported to respond poorly to bone graft procedures and therefore are generally not appropriate candidates for grafting. Bone graft procedures associated with endodontic therapies or minor periradicular surgery may also not be benefitted because such sites typically heal by secondary intention.

Procedure and diagnosis coding

Covered CDT procedure codes referencedCDTCovered

D4263	Bone replacement graft - first site in quadrant
D4264	Bone replacement graft - each additional site in quadrant
D4265	Biologic materials to aid in soft and osseous tissue regeneration, per site
D4266	Guided tissue regeneration - resorbable barrier, per site
D4267	Guided tissue regeneration - non-resorbable barrier, per site
D6103	Bone graft for repair of peri-implant defect - does not include flap entry and closure
D6104	Bone graft at time of implant placement
D7295	Harvest of bone for use in autogenous grafting procedure

Diagnosis codesICD-10

ICD-10 (see CDT book)

IDC-10 CM Diagnoses for Dental Diseases and Conditions: see the current CDT code book for details

Periodontal pocket depth — minimum 5 mm

Minimum periodontal pocket depth5 mm (minimum) based on current 6‑point periodontal charting

Chart recency requirementPeriodontal chart must be dated within 12 months

Charting format6‑point periodontal chart documenting pocket depths

PurposeDemonstrates clinical necessity for bone grafting of periodontal/peri‑implant defects

Provider requirements and authorization

Documentation Required

Clinical review / documentation requirements

Requests for bone grafting procedures may be reviewed for appropriateness by dental directors and may require prior clinical review. Submitting dentists must include any and all clinical information related to the procedural request, including recent, dated radiographic images, a letter of rationale explaining the necessity of the bone graft and whether it is related to another service, a recent patient health history, and a current (within 12 months) dated periodontal chart that follows acceptable reporting guidelines by the ADA.

Recent, dated radiographic images (diagnostic quality, properly oriented and labeled) demonstrating vertical bone defects (within 12 months).
Letter of rationale explaining medical necessity and relationship to other services.
Current (within 12 months) patient health history.
Current (within 12 months) dated 6-point periodontal charting indicating minimum pocket depth of 5 mm.
Current, dated CBCT, photos, narrative and chart notes may be required.

Billing Rule

Adjacency / bundling rule

When the primary procedure is not a covered service, all related adjunctive procedures — including but not limited to bone grafts and use of membranes — are not considered a covered benefit even if those adjunctive procedures are covered by the plan for other services.

Adjunctive procedures performed in support of a non-covered primary procedure will be denied as related to the non-covered service.

Denial Risk

Non-covered conjunctions and limitations

Bone grafts are not considered for benefits when performed in conjunction with soft tissue grafting procedures. Routinely placing bone grafts into extraction sites may not be necessary for complete and adequate healing. The use of biologic materials for soft or osseous tissue regeneration may not be benefitted in conjunction with bone grafts (group contract dependent).

Bone grafts with soft tissue grafting: not considered for benefit.
Bone grafts placed routinely into extraction sites: may not be considered necessary/benefitted.
Use of biologic materials with bone grafts: coverage may be contract-dependent.

Prior Authorization

Provider action highlight

Provider action: Submitting dentists should include all required documentation and be prepared for clinical review by dental directors. Incomplete documentation or procedures tied to a non-covered primary service may result in denial.

Ensure all radiographs, periodontal charting, CBCT (if applicable), photos, narrative and chart notes are submitted and dated within 12 months.
Provide a clear letter of rationale explaining necessity and relation to other services.
Be aware that bone graft procedures generally apply to vertical, multi-walled or narrow defects and class II furcation defects; broad horizontal defects typically do not respond well.

Background and clinical context

Bone grafts are used to replace missing bone of the maxilla or mandible due to periodontal disease and to treat periodontal and peri-implant defects. Grafting is generally confined to vertical, multi-walled or narrow defects and certain class II furcation defects. Requests for bone grafting procedures may be reviewed for appropriateness by dental directors and require submission of supporting clinical documentation, including recent, dated radiographic images, a letter of rationale, recent patient health history, and a current (within 12 months) 6-point periodontal chart demonstrating a minimum pocket depth of 5 mm.

Definitions and accepted standards

Generally accepted standards of dental practice — definition of services a prudent dentist provides

DefinitionDental services that a prudent dentist provides for evaluation, diagnosis or treatment that are consistent with accepted standards, effective for the patient’s condition, not primarily for convenience, not cosmetic, and not more costly than alternatives.

Key elementsIn accordance with generally accepted standards of dental practice; appropriate in type, frequency and extent; considered effective for the patient’s dental injury or disease.

Clinical judgmentRendered by a Dentist exercising prudent clinical judgment for evaluating, diagnosing, or treating dental injury, disease, or symptoms.

ExclusionsNot primarily for convenience of patient or dentist; not cosmetic; not more costly than alternative services.

Appropriate defect types for grafting

Appropriate defect typesVertical, multi‑walled or narrow defects and class II furcation defects

Poorly responsive defect typeBroad horizontal interproximal defects do not respond well to bone graft procedures

Clinical limitationGrafting generally confined to periodontal/peri‑implant defects (group contract dependent)

Related procedures not typically benefittedBone grafts associated with endodontic therapies or minor periradicular surgery may not be benefitted

OpenPayer

Bone Grafts for Surgical Services (Periodontal)

Coverage criteria for bone grafting

Procedure and diagnosis coding

Provider requirements and authorization

Background and clinical context

Definitions and accepted standards