CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Biological Materials Tissue Grafting Endontic (2023 Policy) PDF. Opens in a new window

Defines documentation and clinical criteria for review of biologic materials used to aid soft and osseous tissue regeneration in dentistry (used alone or with other procedures). Applies when coverage is governed by specific group contracts and outlines required pretreatment imaging, periodontal charting, and rationale; provides code examples for informational purposes.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBiological Materials Tissue Grafting Endontic (2023 Policy) PDF. Opens in a new window

Policy CodePolicy N/A

Change TypeRevision (annual review)

Effective Date

Next Review Date

Key ActionProvide pretreatment periapical radiographs, current 6-point periodontal charting showing ≥5mm pocket depths, and a letter of rationale specifying the biologic material to support coverage review.

SourceLink

POLICY UPDATE CHANGES

Policy revised and last reviewed 10/26/2022 (published 01/01/2023).

3Required documentation items

5Minimum pocket depth (mm)

3Example biologic materials listed

Coverage Summary

This policy covers biologic materials used to regenerate dental soft and osseous tissues, whether used alone or in conjunction with other procedures. It applies when group contracts require that dental services meet generally accepted standards of dental practice and may be used to determine medical/dental necessity, but it does not guarantee that a particular service is a covered benefit under a specific member contract.

When coverage is governed by a specific group contract, indications for use must be documented with pretreatment periapical radiographic images dated current (within 12 months), current 6-point periodontal charting showing a minimum pocket depth of >= 5 mm, and a letter of rationale specifying the necessity and type of biologic material.

Documentation and Clinical Criteria for Coverage Review

Documentation and clinical criteria for coverage review

When covered by specific group contract, indications for the use of biologic materials must be documented by:

ALL of the following

Pretreatment periapical radiographic images that are of diagnostic quality, properly oriented, and identified, and dated current (within 12 months).within 12 months
Current, dated periodontal charting (6-point periodontal charting) indicating a minimum of 5mm pocket depths.>= 5 mm
A letter of rationale explaining the necessity of the regeneration procedure, and the type of material being used may be requested (examples: platelet rich plasma (PRP), Emdogain®, recombinant human bone morphogenic protein (rhBMP), GEM 21S®, etc.).
The 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.
This describes exclusion of consideration when combined with listed procedures.

Provider Actions & Documentation Requirements

Documentation Required

Submit diagnostic radiographs

Provide pretreatment periapical radiographic images of diagnostic quality, properly oriented, identified, and dated within 12 months to support coverage review.

Pretreatment radiograph recency: within 12 months

Documentation Required

Provide periodontal charting

Provide current, dated 6-point periodontal charting documenting a minimum of 5mm pocket depths for areas treated.

Documentation Required

Provide letter of rationale

Submit a letter of rationale explaining the necessity of the regeneration procedure and specifying the type of biologic material used (e.g., PRP, Emdogain®, rhBMP, GEM 21S®).

Denial Risk

Exclusion when combined with other regenerative procedures

Claims may not be considered (and could be denied) when biologic materials are 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.

Soft tissue grafting
Bone grafts
Guided tissue regeneration
Ridge augmentation
Periradicular surgery
Placement within extraction sites
Use with other regenerative materials

Background

This policy addresses biologic materials used to regenerate dental soft and osseous tissues and provides the framework for review when group contracts require that dental services meet contractual standards. It is intended to assist in determining medical/dental necessity by outlining required documentation and clinical criteria, but it does not constitute a guarantee of coverage under any specific member contract.

Generally accepted standards of dental practice: Standards based on credible peer-reviewed dental literature, specialty society recommendations, the views of recognized dentists practicing in the relevant clinical area, and other relevant factors from credible sources.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBiological Materials Tissue Grafting Endontic (2023 Policy) PDF. Opens in a new window

Policy CodePolicy N/A

Change TypeRevision (annual review)

Effective Date

Next Review Date

SourceLink

On This Page

D3431	Biological materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery.
D4265	Biologic materials to aid in soft and osseous tissue regeneration, per site.
D4266	Guided tissue regeneration - resorbable barrier per site.

OpenPayer

Biological Materials Tissue Grafting Endontic (2023 Policy) PDF. Opens in a new window

Coverage Summary

Documentation and Clinical Criteria for Coverage Review

Codes (informational)

Provider Actions & Documentation Requirements

Background

Revision History