CurrentBlue Cross Blue Shield - WisconsinPolicy 07-901

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Defines clinical indications, documentation requirements, coverage limitations, and CDT procedure codes related to bone grafting procedures of the maxilla and mandible for dental and oral surgical services under the dental clinical policy.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBone Grafts for Dental Surgical Services (2026 Policy) PDF. Opens in a new window

Policy CodePolicy 07-901

Change TypeRevised (minor editorial refinements)

Effective DateJan 1, 2026

Last ReviewOct 30, 2025

Next Review DateN/A

Key ActionSubmitting dentists must include recent dated radiographic images, a letter of rationale explaining necessity and relation to other services, and a recent patient health history when requesting bone graft procedures.

SourceLink

POLICY UPDATE CHANGES

Policy status marked as Revised with minor editorial refinements to description, clinical indications, criteria, and references noted in 10/31/2024 revision; intent unchanged.

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CurrentBlue Cross Blue Shield - WisconsinPolicy 07-901

Bone Grafts for Dental Surgical Services (2026 Policy) PDF. Opens in a new window

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.

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Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBone Grafts for Dental Surgical Services (2026 Policy) PDF. Opens in a new window

Policy CodePolicy 07-901

Change TypeRevised (minor editorial refinements)

Effective DateJan 1, 2026

Last ReviewOct 30, 2025

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Policy status marked as Revised with minor editorial refinements to description, clinical indications, criteria, and references noted in 10/31/2024 revision; intent unchanged.

CDT codes referenced

3mo / 3yrPost-op / re-entry coverage

12 monthsRequired radiograph recency

Coverage Summary

Overview: This dental clinical policy (Policy # 07-901) addresses coverage of bone grafts for dental and oral surgical services of the maxilla and mandible. The policy stance is mixed — bone grafting may be appropriate and covered in certain clinical circumstances but is subject to documentation, clinical criteria, and plan-specific limitations. Effective date: 2026-01-01. Last review date: 2025-10-30. Subject: Bone grafts for dental and oral surgical services.

Current diagnostic radiographsWithin 12 months

Post-operative management includedImmediate 3 months; surgical re-entry 3 years (contract dependent)

CDT codes referenced16

Medical Necessity Criteria

General Coverage Criteria

Bone grafts may be appropriate and considered for coverage when ALL of the following are met:

ALL of the following

Replace missing bone indication: Bone grafting is to replace missing bone of the maxilla or mandible as a result of congenital anomalies, infection, or trauma.
Submission documentation: Submitting dentists must include any and all clinical information related to the procedural request including, but not limited to, recent, dated radiographic images (current within 12 months when applicable), a letter of rationale explaining the necessity of the bone graft and whether related to another service, and a recent patient health history, if applicable.Current diagnostic radiographs: Within 12 months
Patient assessment: Patients with medical complications or contraindications, demonstration of poor oral hygiene, or habits that compromise the healing process (e.g., smoking) must be considered when evaluating bone graft procedures.
Endodontic/minor periradicular exclusion: Bone graft procedures associated with endodontic therapies or with minor periradicular surgery may not be benefitted because bone typically heals by secondary intention.

Provider Actions & Requirements

Prior Authorization

Submission documentation requirement

Submitting dentists must include recent dated radiographic images, a letter of rationale explaining necessity and relation to other services, and a recent patient health history when requesting bone graft procedures.

D6100
D6103
D6104
D6105
D6106
D6107
D7295
D7921
D7922
D7950
D7951
D7952
D7953
D7955
D7956
D7957

Coding

Relevant CDT codes (listed in policy)mixed

D6100	Implant removal, by report
D6103	Bone graft for repair of peri-implant defect
D6104	Bone graft at time of implant placement
D6105	Removal of implant body not requiring bone removal or flap elevation
D6106	Guided Tissue Regeneration (Implant Site, Resorbable Barrier)
D6107	Guided Tissue Regeneration (Implant Site, Non-Resorbable Barrier)
D7295	Harvest of bone for use in autogenous grafting procedure
D7921	Collection and application of autologous blood concentrate product
D7922	Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site
D7950	Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or non-autogenous, by report

1–10 of 16

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Background and Evidence

Background: Bone grafting adds bone tissue to the jaw to repair fractures, prepare implant sites, correct deformities, or restore or enhance oral/maxillofacial structure and function. Major reconstructive bone graft procedures may be covered under the patient’s medical plan rather than the dental plan.

Evidence summary: The policy references guideline and literature sources supporting clinical considerations, including professional society guidance and systematic reviews (for example, AAP, AAOMS, Cochrane reviews, and peer-reviewed articles) cited in the references section.

Bone graft procedure post-op periodImmediate three months following surgery; surgical re-entry included for three years (contract dependent).

Revision History

2024-10-31revision

Policy status marked as Revised with minor editorial refinements to description, clinical indications, criteria, and references noted in 10/31/2024 revision; intent unchanged.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyBone Grafts for Dental Surgical Services (2026 Policy) PDF. Opens in a new window

Policy CodePolicy 07-901

Change TypeRevised (minor editorial refinements)

Effective DateJan 1, 2026

Last ReviewOct 30, 2025

Next Review DateN/A

SourceLink

On This Page

These are typically not covered.

Post-operative management inclusion: Bone graft procedures include post-operative management for the immediate three months following surgery as well as for any surgical re-entry for three years (contract dependent).Post-operative management included: Immediate 3 months; surgical re-entry covered for 3 years (contract dependent)

Adjunctive procedures to non-covered primary: 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 a covered benefit as they are related to a non-covered service.

Routine extraction site grafting: Routinely placing bone grafts into extraction sites may not be necessary for complete and adequate healing and therefore may not be covered routinely.

Coronectomy exclusion: Bone grafting when submitted with coronectomy is not a covered benefit.

Major reconstructive referral to medical plan: Major bone graft (reconstructive) procedures may be covered under the patient's medical plan rather than the dental plan.

Refer to medical plan coverage for major reconstructive procedures.

Narrative/chart notes: Narrative and chart notes may be required to support medical necessity.

Denial Risk

Adjunctive procedures related to non-covered primary service

Claims for bone grafts and membranes will be denied when submitted as adjunctive procedures related to a primary procedure that is not a covered service.

Documentation Required

Narrative and chart notes may be required

Narrative and chart notes must be provided on request to substantiate medical necessity for bone graft procedures.

Billing Rule

Post-operative care inclusion

Reimbursement for bone graft procedures includes post-operative management for the immediate three months following surgery and for any surgical re-entry for up to three years, subject to contract terms.