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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield WI biologic regeneration Co…
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    CurrentBlue Cross Blue Shield - WisconsinPolicy 03-401

    Biological Materials to Aid in Soft Tissue and Osseous Tissue Regeneration (Endodontic)

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    Defines clinical criteria, coding references, and usage restrictions for biological materials used to regenerate periodontal and osseous tissues in dental/endodontic procedures for Blue Cross Blue Shield - Wisconsin members.

    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyBiological Materials to Aid in Soft Tissue and Osseous Tissue Regeneration (Endodontic)
    Policy CodePolicy 03-401
    Change TypeNo material changes
    Effective Date
    Last ReviewOct 25, 2024
    Next Review DateJan 1, 2025
    Key ActionSubmit prior authorization with diagnostic-quality pretreatment periapical radiographs, current 6-point periodontal charting (minimum 5 mm pockets), and a letter of rationale.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthspretreatment radiograph recency
    >=5 mmminimum pocket depth

    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.

    D3431, D4265, D7921example CDT codes
    01/01/2025document publication

    Coverage Criteria

    Clinical coverage criteria

    Covered when ALL of the following are met

    Documentation: Current, dated (within 12 months), pretreatment periapical radiographic images that are of diagnostic quality.radiograph within 12 months

    Provide diagnostic-quality images dated within 12 months.

    Clinical measurements: Current, dated 6-point periodontal charting as described by the American Academy of Periodontology (AAP) and American Dental Association (ADA) indicating a minimum of 5 mm pocket depths.>= 5 mm pocket depth

    Charting must be current and dated.

    Rationale: A letter of rationale explaining the necessity of the regeneration procedure and the type of material being used (examples: platelet-rich plasma [PRP], Emdogain, recombinant human bone morphogenetic protein [rhBMP], Gem-21S) may be requested.

    Letter may be requested to support medical necessity.

    The policy specifies that biological materials may not be considered when used in conjunction with certain concurrent procedures. Specifically, these materials are not considered when used 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.

    Inclusion or exclusion of a procedure, diagnosis, or device code in this document does not constitute or imply member coverage or guarantee provider reimbursement. Providers must refer to the member's contract benefits in effect at the time of service to determine coverage for an individual member.

    Coding and Key Clinical Measures

    CDT codes (included but not limited to)CPT
    D3431Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery
    D4265Biological material to aid in soft and osseous tissue regeneration, per site
    D7921Collection and application of autologous blood concentrate product
    ICD-10 Diagnoses (reference)ICD-10
    No codes listed
    Periodontal pocket depth — minimum 5 mm
    Minimum pocket depth6-point periodontal charting indicating a minimum of 5 mm pocket depths
    Measurement method6-point periodontal charting as described by AAP and ADA
    Documentation date requirementCharting must be current and dated (within 12 months)
    Radiograph recency — within 12 months
    Required recencyCurrent, dated pretreatment periapical radiographic images within 12 months
    Image qualityImages must be of diagnostic quality
    Use with other documentation

    Provider Actions and Documentation Requirements

    Prior Authorization

    Prior Authorization / Document Submission

    Prior authorization/document submission may require diagnostic radiographs, current 6‑point periodontal charting, and a letter of rationale. CDT codes may be referenced during review.

    • Diagnostic-quality pretreatment periapical radiographs (dated within 12 months)
    • Current, dated 6‑point periodontal charting showing ≥5 mm pocket depths
    • Letter of rationale explaining medical necessity and the specific biologic material to be used (e.g., PRP, Emdogain, rhBMP, Gem-21S)
    Note

    Providers should ensure required pretreatment documentation is uploaded with prior authorization requests or submitted upon request to avoid delays or denials.

    • Confirm radiographs are diagnostic quality and dated within 12 months
    • Ensure periodontal charting follows AAP/ADA 6‑point format and documents required pocket depths
    • Include specifics about the biologic material and intended surgical context in the rationale letter

    Background

    Regenerative therapy using biological materials is intended to regenerate damaged periodontal and osseous tissues rather than relying solely on grafts. These approaches use biological substitutes to restore, maintain, or improve tissue function and can be applied to periodontal defects of natural teeth and dental implants. Examples of products that may be used include platelet-rich plasma (PRP), enamel matrix derivatives (e.g., Emdogain), and recombinant human bone morphogenetic proteins (rhBMP).

    Definitions

    Regenerative therapy / tissue engineering definition — tissue engineering/regenerative medicine description
    DefinitionTissue engineering/regenerative medicine: a process by which damaged tissues are regenerated rather than using grafts by developing biological substitutes that restore, maintain, or improve tissue function.
    Clinical aimRestore or improve periodontal and osseous tissue function using biological substitutes rather than autografts or allografts
    ApplicationsUsed for treatment of periodontal disease defects of natural teeth and dental implants
    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyBiological Materials to Aid in Soft Tissue and Osseous Tissue Regeneration (Endodontic)
    Policy CodePolicy 03-401
    Change TypeNo material changes
    Effective Date
    Last ReviewOct 25, 2024
    Next Review DateJan 1, 2025
    Key ActionSubmit prior authorization with diagnostic-quality pretreatment periapical radiographs, current 6-point periodontal charting (minimum 5 mm pockets), and a letter of rationale.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Key Clinical MeasuresProvider Actions and Documentation RequirementsBackgroundDefinitions
    Radiographs are required along with current 6-point periodontal charting and a letter of rationale as requested
    Documentation Required

    Required Documentation

    Required documentation must be present and current to support medical necessity determinations.

    • Current, dated (within 12 months) diagnostic-quality pretreatment periapical radiographs
    • Current, dated 6‑point periodontal charting as described by AAP and ADA indicating a minimum of 5 mm pocket depths
    • Letter of rationale explaining the necessity of the regeneration procedure and identifying the biologic material to be used
    Denial Risk

    Restricted Concurrent Use

    Biological materials are restricted in concurrent use with certain procedures and contexts and may not be considered when used together.

    • Not considered when used with soft tissue grafting, bone grafts, or guided tissue regeneration
    • Not considered for ridge augmentation or periradicular surgery when used concurrently with other regenerative materials
    • Not considered when placed within extraction sites or utilized with other regenerative materials regardless of specific group plan coverage