CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Biological Materials to Aid Soft and Hard Tissue Grafting (2022 Policy) PDF. Opens in a new window

Clinical policy describing documentation and clinical criteria required when biologic materials (e.g., PRP, Emdogain, rhBMP, Gem-21S) are used to aid soft tissue and osseous tissue regeneration in dental/endodontic care; applies when group contract covers these materials and is used to guide dental necessity review and utilization management.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBiological Materials to Aid Soft and Hard Tissue Grafting (2022 Policy) PDF. Opens in a new window

Policy CodePolicy N/A

Change TypeClarified (annual review)

Effective DateN/A

Next Review DateN/A

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

SourceLink

POLICY UPDATE CHANGES

Revision history shows annual reviews and a revision on 10/30/2021; last review date 01/01/2022.

1Key CDT procedure referenced

5mmMin pocket depth

12moRadiograph currency

Coverage Summary

Clinical policy describing the documentation and clinical criteria required when biologic materials (e.g., PRP, Emdogain, rhBMP, Gem-21S) are used to aid soft tissue and osseous tissue regeneration in dental/endodontic care; applies when a specific group contract covers these materials and is used to guide dental necessity review and utilization management. When covered by a specific group contract, indications must be documented with pretreatment periapical radiographs dated within 12 months, current 6‑point periodontal charting showing minimum 5 mm pocket depths, and a letter of rationale specifying the necessity and the biologic material.

Provider Action Items

Documentation Required

Submit pretreatment radiographs

Provide pretreatment periapical radiographic images of diagnostic quality that are properly oriented, identified, and dated within 12 months.

Documentation Required

Submit periodontal charting

Provide current, dated 6‑point periodontal charting per AAP/ADA demonstrating minimum 5 mm pocket depths.

Documentation Required

Provide letter of rationale

Provide a letter of rationale explaining the necessity of the regeneration procedure and specifying the biologic material to be used (examples: PRP, Emdogain, rhBMP, Gem-21S).

Denial Risk

Excluded concomitant uses

Claims may not be considered or covered when biologic materials are used in conjunction with specified procedures or other regenerative materials.

Affected CDT code: D3431

Background and Definitions

Policy addresses the use of biologic materials for dental soft tissue and osseous regeneration whether used alone or as adjunctive regenerative therapy for periodontal defects of natural teeth and dental implants. The plan performs review of these uses to ensure services meet contractual requirements and generally accepted standards of dental care, recognizing that a determination of medical or dental necessity does not itself guarantee benefit coverage under the member's dental plan.

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

Revision History

2017-02-08creation

Policy created (revision history initial entry).

2018-02-06annual_review

Annual revision noted in revision history.

2020-10-07annual_review

Annual review recorded in revision history.

2020-12-04annual_review

Annual review recorded in revision history.

2021-10-30annual_review

Annual review recorded in revision history.

2022-01-01last_reviewLatest

Last review date; latest substantive policy language unchanged.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBiological Materials to Aid Soft and Hard Tissue Grafting (2022 Policy) PDF. Opens in a new window

Policy CodePolicy N/A

Change TypeClarified (annual review)

Effective DateN/A

Next Review DateN/A

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

SourceLink

On This Page

OpenPayer

Biological Materials to Aid Soft and Hard Tissue Grafting (2022 Policy) PDF. Opens in a new window

Coverage Summary

Documentation and Clinical Criteria for Coverage

Coding

Provider Action Items

Background and Definitions

Revision History