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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield WI Guided Tissue Regenerati…
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    CurrentBlue Cross Blue Shield - WisconsinPolicy 04-209

    Guided Tissue Regeneration — Dental Clinical Policy

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    Policy governing coverage and clinical criteria for guided tissue regeneration procedures for periodontal and peri-implant defects for Blue Cross Blue Shield - Wisconsin members.

    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyGuided Tissue Regeneration — Dental Clinical Policy
    Policy CodePolicy 04-209
    Change TypeNo material clinical or coverage changes
    Effective DateJan 1, 2025
    Last ReviewOct 28, 2024
    Next Review DateJan 1, 2025
    Key ActionObtain current (within 12 months) pretreatment radiographs and post-initial therapy 6‑point periodontal charting showing pocket depths ≥5 mm before submission.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6CDT codes listed
    10criteria points
    12diagnostic recency (months)

    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.

    3m / 3ypost-op / re-entry

    Coverage and Medical Necessity Criteria

    Medical necessity criteria

    Covered when ALL of the following are met

    Anatomic defect and indications: Defect is vertical, multi-walled or narrow with areas of vertical bone loss or a Class II furcation; generally confined to periodontal and peri-implant defects; may be allowed with implants (contract dependent).

    criteria 1,2,7

    Exclusions and limitations: Not covered when associated with endodontic therapies or minor periradicular surgery; not considered when performed in conjunction with soft tissue grafting; use of biologic materials for soft or osseous tissue regeneration will not be considered in conjunction with guided tissue regeneration; major reconstructive procedures are contract dependent—check medical plan for coverage.

    criteria 3,6,8,10

    Documentation: Provide current (within 12 months), dated, properly oriented pretreatment radiographic images demonstrating vertical bone defects and current (within 12 months), dated post-initial therapy 6-point periodontal charting with pocket depths >= 5 mm.

    criteria 4,5

    Postoperative management and follow-up: Post-operative management included for the immediate three months following surgery and for any surgical re-entry for three years (contract dependent).

    criteria 9

    threshold":"","note":"criteria 11"}

    Guided tissue regeneration procedures performed in association with endodontic therapies or with minor periradicular surgery are typically not a covered benefit. The policy notes that bone in these situations "heals by secondary intention," and therefore these procedures are generally excluded from coverage.

    The routine performance of guided tissue regeneration for extraction sites is generally not considered necessary to achieve complete and adequate healing; therefore, such routine use is not supported as a covered indication.

    Procedure Codes and Key Clinical Thresholds

    CDT codesCPT
    D3432Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery
    D4266Guided tissue regeneration - resorbable barrier, per site
    D4267Guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal)
    D7956Guided tissue regeneration, edentulous area - resorbable barrier, per site
    D7957Guided tissue regeneration, edentulous area - non-resorbable barrier, per site
    Periodontal pocket depth — clinical threshold
    Minimum pocket depth>= 5 mm (current within 12 months, post-initial therapy 6‑point periodontal charting)
    Recency requirementCharting must be current within 12 months
    Charting typeDated, post-initial therapy 6-point periodontal charting

    Provider Responsibilities and Authorization

    Prior Authorization

    Prior Authorization / Benefit Verification

    Prior authorization and benefit verification are contract dependent. Check the member's plan prior to scheduling or performing guided tissue regeneration.

    • Contract-dependent — verify prior authorization and benefits with Blue Cross Blue Shield - Wisconsin before treatment
    Denial Risk

    Denial Risk

    Claims may be denied when guided tissue regeneration is performed in association with endodontic therapies or minor periradicular surgery, or when used for extraction sites where routine healing is expected. Also, guided tissue regeneration performed in conjunction with soft tissue grafting or the use of biologic materials for soft or osseous tissue regeneration will not be considered for benefits in combination.

    • Not covered when associated with endodontic therapies or minor periradicular surgery — bone heals by secondary intention

    Background

    Guided tissue regeneration is a surgical procedure intended to achieve new bone, cementum and periodontal ligament (PDL) attachment to a periodontally diseased tooth. Clinically, it is applied to vertical, multi-walled or narrow defects with vertical bone loss and to certain furcation defects where regeneration of attachment is the therapeutic intent. The policy confines use to these specific defect types and requires documentation of defect severity and prior therapy to support medical necessity.

    Definitions

    Guided tissue regeneration — definition
    DefinitionA surgical procedure intended to achieve new bone, cementum and periodontal ligament (PDL) attachment to a periodontally diseased tooth.
    Typical indicationsClass II furcation involvement; vertical defects (intrabony and infrabony); adjunctive use with bone grafting.
    Primary goalAchieve new attachment (bone, cementum, PDL) to a periodontally diseased tooth.
    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyGuided Tissue Regeneration — Dental Clinical Policy
    Policy CodePolicy 04-209
    Change TypeNo material clinical or coverage changes
    Effective DateJan 1, 2025
    Last ReviewOct 28, 2024
    Next Review DateJan 1, 2025
    Key ActionObtain current (within 12 months) pretreatment radiographs and post-initial therapy 6‑point periodontal charting showing pocket depths ≥5 mm before submission.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaProcedure Codes and Key Clinical ThresholdsProvider Responsibilities and AuthorizationBackgroundDefinitions
  1. Not considered when performed with soft tissue grafting procedures
  2. Use of biologic materials for soft or osseous tissue regeneration will not be considered in conjunction with guided tissue regeneration
  3. Routine use for extraction sites may be unnecessary and subject to denial
    4. Documentation Required

    Documentation Requirements

    Documentation must demonstrate medical necessity for periodontal-guided tissue regeneration. Required documentation includes current, dated diagnostic records and periodontal measurements.

    • Current (within 12 months) dated, properly oriented pretreatment radiographic images showing vertical bone defects
    • Current (within 12 months) dated post-initial therapy 6-point periodontal charting with pocket depths ≥ 5 mm
    • Documentation that the defect is a vertical, multi-walled or narrow defect (or class II furcation) appropriate for guided tissue regeneration
    • For major reconstructive procedures, verify the patient’s medical plan for potential coverage
    Note

    Provider Actions

    Provider actions — ensure prior authorization/benefit verification, assemble required documentation, and avoid billing for procedures unlikely to be covered.

    • Verify member contract and obtain prior authorization when required
    • Include all required current (within 12 months) pretreatment radiographs and post-initial therapy periodontal charting with claims
    • Do not bill guided tissue regeneration when performed with endodontic or minor periradicular surgery, with soft tissue grafting, or with biologic materials for concurrent soft/osseous regeneration
    • Check the patient’s medical plan for coverage of major reconstructive guided tissue regeneration procedures
    • Document defect type (vertical multi-walled, narrow defect, or class II furcation) to support medical necessity