CurrentBlue Cross Blue Shield - WisconsinPolicy 07-901

Bone Grafts for Dental and Oral Surgical Services

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Policy governing clinical appropriateness and use of bone grafting and graft substitutes for dental and oral surgical procedures; applies to dentists and dental reviewers assessing benefit coverage under the plan.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBone Grafts for Dental and Oral Surgical Services

Policy CodePolicy 07-901

Change TypeNo material changes

Effective Date

Last ReviewNov 1, 2023

Next Review Date

Key ActionSubmit prior review requests with recent dated radiographs (within 12 months), a letter of rationale, recent health history, and periodontal chart if applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CDT 2024code set edition cited

3 monthspost-op management

3 years

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CurrentBlue Cross Blue Shield - WisconsinPolicy 07-901

Bone Grafts for Dental and Oral Surgical Services

Customize your policy alerts

Sign up for Blue Cross Blue Shield - Wisconsin Policy 07-901 alerts

Get alerted when Policy 07-901 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBone Grafts for Dental and Oral Surgical Services

Policy CodePolicy 07-901

Change TypeNo material changes

Effective Date

Last ReviewNov 1, 2023

Next Review Date

Key ActionSubmit prior review requests with recent dated radiographs (within 12 months), a letter of rationale, recent health history, and periodontal chart if applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CDT 2024code set edition cited

3 monthspost-op management

3 years

Coverage Criteria

Appropriateness criteria

Covered when ALL of the following are met:

Primary indications: Replacement of missing bone of the maxilla or mandible due to congenital anomalies, infection, or trauma

Documentation required: Submission must include recent, dated pretreatment radiographic images (current within 12 months), a letter of rationale explaining necessity and relationship to any other service, recent patient health history, and a recent dated periodontal chart if applicable; narrative and chart notes may be required

Refer to prior review and documentation requirements for details

Patient factors to consider: Patients with medical complications or contraindications, demonstration of poor oral hygiene, or habits that compromise healing (eg, smoking) must be considered when evaluating appropriateness

Procedure relationship and limitations: Bone graft procedures associated with endodontic therapies or minor periradicular surgery may not be benefitted because bone typically heals by secondary intention; when the primary procedure is not covered, all related adjunctive procedures (including bone grafts and membranes) are not covered

Postoperative and follow-up: Coverage for bone graft procedures includes postoperative management for the immediate three months following surgery and coverage for any surgical re-entry for up to three years (group contract dependent)

Check member’s medical plan for coverage of major reconstructive procedures

Bone graft procedures associated with endodontic therapies or minor periradicular surgery are generally not considered beneficial because bone typically heals by secondary intention. Additionally, when the primary procedure is not a covered service, all related adjunctive procedures — including bone grafts and membranes — are not a covered benefit under the plan.

Routinely placing bone grafts into extraction sites may be unnecessary for complete and adequate healing and therefore may not be considered medically necessary. Providers should document clinical rationale when grafting an extraction site to support medical necessity.

Coding

Covered CDT Codes (examples listed)CDT

D6100	Implant removal, by report
D6103	Bone graft for repair of peri-implant defect
D6104	Bone graft at time of implant placement
D7295	Harvest of bone for use in autogenous grafting procedure
D7950	Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or non-autogenous, by report
D7951	Sinus augmentation via a lateral open approach
D7952	Sinus augmentation via a vertical approach
D7953	Bone replacement graft for ridge preservation
D7955	Repair of maxillofacial soft and/or hard tissue defect

Pretreatment radiographs — current within 12 months

RequirementPretreatment diagnostic radiographic images must be current (dated within 12 months) before bone graft procedures.

Image typeDated, diagnostic, pretreatment radiographic images (as submitted by provider).

Documentation contextRadiographs must be included with the request and are part of the clinical information reviewed for appropriateness.

Related timingPolicy also requires documentation of postoperative management for 3 months and surgical re-entry follow-up for up to 3 years (group contract dependent).

Provider Actions & Requirements

Documentation Required

Required documentation

Requests for bone grafting procedures may be reviewed for appropriateness by dental professionals. Submitting dentists must include any and all clinical information related to the procedural request including, but not limited to, recent, dated radiographic images (within 12 months), a letter of rationale explaining the necessity of the bone graft and whether related to another service, a recent patient health history, and a recent dated periodontal chart, if applicable. Narrative and chart notes may be required.

Current (within 12 months), dated, diagnostic pretreatment radiographic images required
Include letter of rationale describing necessity and relation to other services
Provide recent patient health history and periodontal chart when applicable
Narrative and chart notes may be requested

Prior Authorization

Prior review and documentation required

Background

Bone grafting is used to replace missing bone of the maxilla or mandible resulting from congenital anomaly, infection, or trauma. The policy emphasizes that such dental services must meet generally accepted standards of dental practice, be effective for the patient’s condition, and be supported by appropriate documentation. Requests for bone grafting may be reviewed by dental professionals and require submission of supporting clinical materials, including current (within 12 months), dated diagnostic pretreatment radiographs, a letter of rationale, recent health history, and periodontal chart when applicable. The policy also notes patient factors that affect appropriateness (for example, medical complications, contraindications, poor oral hygiene, or habits such as smoking) and defines coverage limits such as inclusion of post-operative management for the immediate three months following surgery and consideration of surgical re-entry follow-up up to three years (group contract dependent).

Definitions

Generally accepted standards of dental practice — definition

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

PurposeStandards guide dental services that a prudent dentist provides for evaluating, diagnosing, or treating dental injury or disease—ensuring type, frequency, and extent are effective for the patient and not primarily for convenience or cosmetic reasons.

Evidence sourcesIncludes peer‑reviewed dental literature and specialty society recommendations explicitly recognized by the practicing dental community.

Clinical judgmentAlso incorporates the views of recognized dentists practicing in the relevant clinical area and other credible sources as applicable.