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    v1.0.28
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialBlue Cross Blue Shield WI periodontal bone graftin…
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    CurrentBlue Cross Blue Shield - WisconsinPolicy 04-201

    Periodontal bone grafting — coverage criteria

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    This policy governs coverage and clinical criteria for periodontal bone grafting procedures for retained natural teeth and peri-implant defects for Blue Cross Blue Shield - Wisconsin members.

    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyPeriodontal bone grafting — coverage criteria
    Policy CodePolicy 04-201
    Change TypeNo material change
    Effective DateJan 1, 2026
    Last ReviewOct 14, 2025
    Next Review DateJan 1, 2026
    Key ActionSubmit prior authorization with dated radiographs, a letter of rationale, current periodontal charting, and patient health history to support medical necessity.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    14clinical criteria items (some archived)
    9procedure codes referenced

    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.

    12 mo
    radiographs/charting recency

    Coverage and Medical Necessity Criteria

    Medical necessity criteria

    Covered when ALL of the following are met

    Indication: Bone grafting is for replacing missing bone of the maxilla or mandible resulting from periodontal disease or to treat periodontal/peri-implant defects (contract dependent).

    See clinical indications

    Defect type: Defect is vertical, multi-walled, narrow or a Class II furcation defect; wide horizontal interproximal defects are not appropriate for bone grafting due to limited positive outcomes.

    Criteria 1-2

    Documentation: Diagnostic-quality, properly oriented, dated pretreatment radiographs within 12 months demonstrating vertical bone defects; current (within 12 months) post-initial therapy 6-point periodontal charting showing minimum pocket depth of 5 mm; letter of rationale describing necessity and relation to other services; recent patient health history and supporting materials (CBCT, photos, narrative) as needed.radiographs/charting within 12 months; pocket depth >= 5 mm

    Criteria 5-6,12,14

    Conservative therapy first: Completion of initial periodontal therapy (e.g., scaling and root planing) with a minimum four-week healing interval prior to surgical bone grafting to allow assessment of non-surgical therapy success.>= 4 weeks after initial therapy

    Criteria 13

    Procedure relation and exclusions: Bone grafts performed in conjunction with soft tissue grafting procedures or related to non-covered primary procedures are not considered benefits; bone grafts associated solely with endodontic therapies or minor periradicular surgery are generally not benefited because bone typically heals by secondary intention.

    Criteria 3,4,10

    Staging and diagnosis: Periodontal diagnosis must follow current AAP and ADA guidelines including staging and grading per professional standards.

    Criteria 14

    Bone grafting requests will be denied when the graft is performed in direct conjunction with soft tissue grafting procedures or when the graft is related to a non-covered primary procedure. The policy states that bone grafts are not considered for benefits when performed in conjunction with soft tissue grafting procedures, and grafts related to non-covered primary services are similarly excluded from benefit consideration. Providers should ensure the requested bone graft is a standalone, covered periodontal or peri-implant procedure and not ancillary to a non-covered service or combined soft tissue procedure to avoid denial.

    Bone graft procedures associated with endodontic therapies or minor periradicular surgery are generally not considered benefits because bone typically heals by secondary intention in these clinical situations. The policy explicitly states that such grafts "may not be benefitted," so submissions for bone grafts performed to address endodontic or minor periradicular indications should not be expected to meet coverage criteria.

    Coding, Timing, and Clinical Thresholds

    Covered CDT CodesCDTCovered
    D4263Bone replacement graft - retained natural tooth- first site in quadrant.
    D4264Bone replacement graft - retained natural tooth- each additional site in quadrant.
    D4265Biologic materials to aid in soft and osseous tissue regeneration, per site.
    D4266Guided tissue regeneration - resorbable barrier, per site.
    D4267Guided tissue regeneration - non-resorbable barrier, per site.
    D4286Removal of non-resorbable barrier.
    D6103Bone graft for repair of peri-implant defect - does not include flap entry and closure.
    D7295Harvest of bone for use in autogenous grafting procedure.
    D7921Collection and application of autologous blood concentrate product.
    inv-05: Minimum pocket depth after initial therapy
    Minimum required pocket depth>= 5 mm (post-initial therapy, 6-point periodontal chart)
    Chart timingMust be current and dated within 12 months
    Chart type6-point periodontal charting (post-initial therapy)
    PurposeDemonstrates clinical need for bone grafting by documenting pocket depths consistent with vertical bone defects
    inv-06: Recency of radiographs and periodontal charting
    Maximum age for radiographs and periodontal chartingWithin 12 months

    Provider Requirements, Prior Authorization, and Documentation

    Prior Authorization

    Prior Authorization Required

    Prior authorization is required for bone graft procedure codes. Submit a complete prior authorization request before performing the service to ensure benefit determination and avoid claim denials.

    • Include all required clinical documentation listed below with the prior authorization submission.
    • Failure to obtain prior authorization may result in denial or delayed payment.
    Documentation Required

    Required Documentation for Submission

    Submissions must include recent, dated radiographic images, a letter of rationale explaining the necessity of the bone graft and whether it is related to another service, a recent patient health history, and a recent dated periodontal chart (within 12 months) following ADA reporting guidelines.

    • Current (within 12 months) pretreatment diagnostic-quality, properly oriented radiographs demonstrating vertical bone defects (CBCT when applicable).

    Background

    Periodontal bone grafting is a surgical procedure that places graft material (autograft, allograft, or alloplastic) into an area of bone loss to restore or regenerate alveolar bone lost from periodontal disease. These procedures are typically directed at narrow, vertical, multi-walled defects or Class II furcation defects where regeneration is more likely to succeed; by contrast, wide horizontal interproximal defects have limited positive outcomes. Bone grafting may be performed for retained natural teeth or peri-implant defects and is intended to provide a scaffold for new bone formation and support of the dentition or implant.

    Definitions

    inv-14: Class II furcation defect
    DefinitionLoss of bone between the roots of a multirooted tooth (typically molars) where the defect extends into the furcation area
    Clinical classificationClass II furcation: vertical loss of bone into the furcation that may be appropriate for periodontal bone grafting
    Typical treatment indicationBone grafting may be appropriate for Class II furcation defects as part of periodontal/peri-implant defect management
    Prognostic noteClass II furcations are specifically listed as defect types generally suitable for grafting; wide horizontal interproximal defects are less suitable
    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyPeriodontal bone grafting — coverage criteria
    Policy CodePolicy 04-201
    Change TypeNo material change
    Effective DateJan 1, 2026
    Last ReviewOct 14, 2025
    Next Review DateJan 1, 2026
    Key ActionSubmit prior authorization with dated radiographs, a letter of rationale, current periodontal charting, and patient health history to support medical necessity.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaCoding, Timing, and Clinical ThresholdsProvider Requirements, Prior Authorization, and DocumentationBackgroundDefinitions
    Required radiographs
    Diagnostic-quality, properly oriented, dated pretreatment radiographic images demonstrating vertical bone defects
    Required chartingCurrent (within 12 months), dated post-initial therapy 6-point periodontal charting following ADA reporting guidelines
    Additional supportive imagingCBCT, photos, narrative and chart notes may be considered
    inv-07: Healing interval after initial periodontal therapy
    Minimum healing interval after initial periodontal therapyMinimum 4 weeks prior to surgical bone grafting
    Purpose of intervalAllows tissues to heal and permits assessment of success or failure of non-surgical therapy (e.g., scaling and root planing)
    Requirement contextCompletion of initial periodontal therapy is required before surgical treatment for bone grafting
  1. Current (within 12 months), dated post-initial therapy 6‑point periodontal charting indicating minimum pocket depth of 5 mm.
  2. Photographs, narrative chart notes, and a letter of rationale describing necessity and relation to other services.
    3. Denial Risk

    Denial Risk for Insufficient Documentation

    Missing, incomplete, or insufficient clinical documentation may result in denial of the bone graft claim. Common deficiencies include lack of dated radiographs, absence of periodontal charting within 12 months, no letter of rationale, or documentation showing the primary procedure is non-covered.

    • Bone grafts performed with a non-covered primary procedure (including adjunctive procedures related to non-covered services) are not benefits and are subject to denial.
    • Bone grafts performed in conjunction with soft tissue grafting are not considered for benefits.
    • If initial periodontal therapy (e.g., scaling and root planing) was not completed with a minimum four-week healing interval prior to surgery, benefits may be denied.