CurrentDelta Dental of OhioPolicy 282.32.v3

Clinical Criteria for Periodontal Regenerative Treatment

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Establishes clinical criteria for determining the medical necessity and clinical appropriateness of periodontal regenerative treatment, including bone replacement grafts, biologic materials, and guided tissue regeneration, when clinical review is required by a member’s dental plan.

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Periodontal Regenerative Treatment

Policy CodePolicy 282.32.v3

Change TypeNo material change

Effective DateJune 21, 2025

Next Review DateN/A

Key ActionSupport procedures requiring clinical review with documentation of a generally accepted indication and the applicable clinical, radiographic, periodontal, and diagnostic records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Applicable dental procedure codes

2- or 3-wallRegenerative defect morphology

Grade I-IIFurcation indication

12 monthsCharting age limit

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CurrentDelta Dental of OhioPolicy 282.32.v3

Clinical Criteria for Periodontal Regenerative Treatment

Customize your policy alerts

Sign up for deltadentalofohio Policy 282.32.v3 alerts

Get alerted when Policy 282.32.v3 changes without checking for updates manually.

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Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Periodontal Regenerative Treatment

Policy CodePolicy 282.32.v3

Change TypeNo material change

Effective DateJune 21, 2025

Next Review DateN/A

Key ActionSupport procedures requiring clinical review with documentation of a generally accepted indication and the applicable clinical, radiographic, periodontal, and diagnostic records.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5Applicable dental procedure codes

2- or 3-wallRegenerative defect morphology

Grade I-IIFurcation indication

12 monthsCharting age limit

2Eligible biologic products

Medical Necessity and Coverage Criteria

Generally Accepted Indications

Coverage requires documentation in the patient's dental record establishing at least one generally accepted indication for periodontal regenerative treatment. If the patient does not meet the published qualifying criteria, relevant clinician documentation explaining the necessity of treatment for an otherwise unlisted condition may also be considered.

AT LEAST ONE of the following indications

2-wall or 3-wall vertical intrabony osseous defects, meaning defects surrounded by 2 or 3 walls of bone that generally present a higher potential for regeneration.
Grade I-II furcation involvement, meaning furcation involvement that has not progressed to a through-and-through defect and whose bony architecture presents a potential for regeneration.
Class I-II tooth mobility when presurgical splinting has been performed.

Potentially Not Medically Necessary or Inadvisable Treatment

Depending on the patient's clinical circumstances, periodontal regenerative treatment may be considered not medically necessary, inadvisable, or deficient in clinical quality and may result in disapproval of benefits when any of the following apply:

ANY of the following conditions

Absence of bone loss.
0-wall or 1-wall intrabony defects, wide crater-type defects, or horizontal bone loss, where the bony architecture generally presents a lower potential for regeneration.
Grade III furcation involvement, consisting of a through-and-through furcation defect that generally presents a lower potential for regeneration.
Class I-II tooth mobility when presurgical splinting has not been performed.
Class III tooth mobility.
A medical condition or treatment history that makes periodontal surgery inadvisable, including, but not limited to, a history of bisphosphonate treatment or chemotherapy or radiation therapy of the head and neck.

Biologic Materials and Additional Procedure Criteria

Depending on the patient's condition and circumstances, the following additional criteria may apply to coverage determinations for periodontal regenerative treatment involving biologic materials.

Biologic material criteria

An access flap of some type must be performed in conjunction with application of a biologic material for the biologic-material procedure to be considered for benefit payment.
Consistent with the American Academy of Periodontology 2022 best evidence consensus statement, biologics may be beneficial for patients with compromised wound healing, defects with a lower potential for regeneration, situations requiring a shortened healing time, or patients who have had poor results with conventional treatment approaches.
Dental benefit programs may establish limitations for biologics used with other periodontal, endodontic, or oral surgery procedures, including periodontal soft tissue grafts, periradicular surgery, implants, tooth extraction, sinus augmentation, or ridge preservation procedures.
For benefit review, a communicating osseous defect between two adjacent teeth is considered a single site.

Biologic materials currently eligible for benefit consideration are limited to Emdogain (enamel matrix derivative protein) and GEM-21S (growth factor-derived enhanced matrix). Biologic products other than Emdogain and GEM-21S are considered investigational.

Repetition of periodontal regenerative procedures following recurrence of periodontal breakdown is considered investigational because scientifically conducted studies have not documented its effectiveness.

Unless otherwise established by a dental benefit program, periodontal regenerative treatment is eligible for benefit coverage for treatment of natural teeth only.

Additional conditions that may be considered not medically necessary or inadvisable include patient noncompliance with oral hygiene procedures and supportive care; lifestyle-associated risk factors that may negatively affect bone regeneration, such as heavy smoking; circumstances in which strategic extraction and placement of an implant is more appropriate based on accepted standards of care; and treatment performed on a tooth with a hopeless periodontal, endodontic, or structural prognosis when extraction is advisable.

Applicable Codes and Clinical Coding Details

Applicable Dental Procedure CodesCPT

D4263	bone replacement graft - retained natural tooth - first site in quadrant
D4264	bone replacement graft - retained natural tooth - each additional site in quadrant
D4265	biologic materials to aid in soft and osseous tissue regeneration, per site
D4266	guided tissue regeneration, natural - resorbable barrier, per site
D4267	guided tissue regeneration, natural - non-resorbable barrier, per site

Vertical intrabony osseous defect

Defect typeVertical intrabony osseous defect

Bone-wall morphologySurrounded by 2 or 3 walls of bone

Regenerative potentialGenerally presents a higher potential for regeneration

Furcation involvement

ConditionFurcation involvement

Eligible gradeGrade I-II

Defect descriptionBone loss has not progressed to a through-and-through defect

Submission Requirements and Benefit Review Risks

Documentation Required

Document Medical Necessity and Clinical Appropriateness

When benefit payment requires a determination that periodontal regenerative treatment is medically necessary and clinically appropriate, the dental record must document a generally accepted indication. If the patient does not meet the published qualifying criteria, submit relevant clinician documentation explaining why coverage is necessary for the condition.

Generally accepted indications include 2-wall or 3-wall vertical intrabony osseous defects.
Grade I-II furcation involvement may qualify when the defect is not through-and-through and the bony architecture has regenerative potential.
Class I-II tooth mobility may qualify when presurgical splinting has been performed.

Documentation Required

Submit Required Clinical and Radiographic Records

Base the treatment plan on a thorough clinical and radiographic examination and submit the applicable records with the claim when coverage depends on medical-necessity or clinical-appropriateness review.

Preoperative diagnostic-quality radiographs, including bitewing images showing the teeth in the planned treatment areas.

Clinical Background

Periodontal disease can destroy alveolar bone, creating intrabony osseous defects or furcation involvement that compromise periodontal support and tooth retention. Periodontal regenerative treatment is intended to promote new periodontal attachment and bone formation using bone replacement grafts, biologic materials, guided tissue regeneration barriers, or combinations of these techniques. Treatment generally involves flap reflection, defect preparation and debridement, placement of regenerative materials, and wound closure; nonresorbable barriers require subsequent removal.

Definitions

Autograft

Material typeBone replacement material

SourceThe patient’s own bone

HarvestingHarvested from a donor site

Allograft

Material typeBone replacement material

SourceNon-autologous human bone

UseUsed for periodontal osseous defects as a bone replacement graft

Policy Summary

PayerDelta Dental of Ohio

PolicyClinical Criteria for Periodontal Regenerative Treatment

Policy CodePolicy 282.32.v3

Change TypeNo material change

Effective DateJune 21, 2025

Next Review DateN/A

Key ActionSupport procedures requiring clinical review with documentation of a generally accepted indication and the applicable clinical, radiographic, periodontal, and diagnostic records.

SourceLink

On This Page

When the dental benefit program has program-specific criteria defining when periodontal regenerative treatment is medically necessary and eligible for coverage, or has established other coverage limitations, those criteria apply when medical necessity is evaluated.

Regenerative potentialThe bony architecture presents a potential for regeneration

Tooth mobility

Supportive mobility rangeClass I-II tooth mobility

Required conditionPresurgical splinting must have been performed

Class III mobilityGenerally considered not medically necessary, inadvisable, or deficient in clinical quality

Preoperative periodontal charting

Chart typePreoperative six-point periodontal pocket depth charting

TimingPerformed within 12 months of treatment

Required documentationClinical attachment loss, tooth mobility, bleeding on probing, and furcation involvement

Intraoral photographs of involved areas when radiographs do not adequately demonstrate the need for the submitted services.

Preoperative six-point periodontal pocket-depth charting performed within 12 months of treatment, documenting clinical attachment loss, tooth mobility, bleeding on probing, and furcation involvement.

Documentation consistent with the patient record explaining the diagnostic rationale, including supporting information from the patient's dental and medical histories.

Delta Dental of Ohio may request other relevant clinical information needed to make a coverage decision.

Denial Risk

Watch for Low Regenerative Potential and Denial Risks

Treatment may be determined not medically necessary, inadvisable, or deficient in clinical quality when the condition has low regenerative potential, the patient is not an appropriate surgical candidate, or accepted standards of care favor another treatment.

Absence of bone loss; 0-wall or 1-wall intrabony defects; wide crater-type defects; or horizontal bone loss.
Grade III furcation involvement or Class III tooth mobility.
Class I-II tooth mobility when presurgical splinting has not been performed.
Medical conditions or treatment history making periodontal surgery inadvisable, including bisphosphonate treatment or chemotherapy or head-and-neck radiation therapy.
Non-compliance with oral hygiene or supportive care, or lifestyle-associated risks such as heavy smoking that may negatively affect bone regeneration.
Strategic extraction and implant placement is more appropriate under accepted standards of care.
The tooth has a hopeless periodontal, endodontic, or structural prognosis and extraction is advisable.

Denial Risk

Check Biologic and Repeat-Procedure Restrictions

Biologic-material procedures must meet additional requirements, and repeat periodontal regenerative procedures after recurrent periodontal breakdown are currently considered investigational because effectiveness is not adequately documented.

An access flap must be performed with application of a biologic material for the biologic-material procedure to be considered for benefit payment.
Biologic use may be beneficial for compromised wound healing, defects with lower regenerative potential, situations requiring shortened healing time, or poor results with conventional treatment.
Eligible biologic products are limited to Emdogain (enamel matrix derivative protein) and GEM-21S (growth factor-derived enhanced matrix); other biologics are considered investigational.
Repetition of periodontal regenerative procedures after recurrence of periodontal breakdown is considered investigational.

Billing Rule

Confirm Tooth and Concurrent-Procedure Limitations

Unless a dental benefit program establishes otherwise, periodontal regenerative treatment is eligible for benefit coverage only for natural teeth. Program-specific limitations may also apply when biologics are used with other periodontal, endodontic, or oral surgery procedures.

Benefit programs may limit biologic coverage when used with periodontal soft-tissue grafts, periradicular surgery, implants, tooth extraction, sinus augmentation, or ridge-preservation procedures.
A communicating osseous defect between two adjacent teeth is considered a single site for benefit review.
Apply any dental benefit program criteria that define medical necessity, eligibility, or other limitations for periodontal regenerative treatment.

Denial Risk

Incomplete Documentation May Result in Disapproval

If the treating practitioner cannot provide the applicable clinical and radiographic information needed for medical-necessity and clinical-appropriateness review, benefit payment may be disapproved.

Missing or inadequate preoperative radiographs, photographs when needed, periodontal charting, or diagnostic rationale may prevent approval.
Submit supporting dental and medical history information and any other relevant clinical information requested for coverage review.
Government regulations or the member's dental plan provisions defining medical necessity and clinical appropriateness may take precedence over these criteria.

Xenograft

Material typeBone product

SourceHarvested from a non-human source

UseUsed as a bone replacement graft for periodontal osseous defects

Alloplastic bone substitute

Material typeSynthetic bone substitute

PurposeProvides a scaffold for bone formation

ApplicationUsed in bone replacement grafting for periodontal osseous defects

Guided tissue regeneration

Treatment typeGuided tissue regeneration

Barrier placementA barrier membrane is placed over a treated periodontal osseous defect

PurposePrevents faster-growing epithelial and connective-tissue cells from entering the healing surgical wound site

Membrane typesBarriers can be resorbable or nonresorbable

2-wall or 3-wall vertical intrabony osseous defect

Defect typeVertical intrabony osseous defect

Bone-wall morphologySurrounded by 2 or 3 walls of bone

Regenerative potentialGenerally presents a higher potential for periodontal regeneration

Furcation involvement

ConditionFurcation involvement

Defect descriptionBone loss has not progressed through and through the furcation

Regenerative gradesGrade I-II involvement generally has greater regenerative potential than Grade III