Dental Clinical Policy
Defines clinical review criteria and documentation requirements for the use of biologic materials to aid soft tissue and osseous tissue regeneration in dental procedures (including periodontal defects and periradicular surgery) when covered by specific group contracts. Includes coding for informational purposes and notes exclusions when used with other regenerative procedures.
Document revised (03-401 Revised) with annual review history entries through 12/4/2020.
Coverage Summary
Scope: This policy defines clinical review criteria and documentation requirements for the use of biologic materials to aid in soft tissue and osseous tissue regeneration in dental procedures (including periodontal defects and periradicular surgery). Review is performed as part of utilization management because plan coverage depends on specific group contract terms and whether the service meets generally accepted standards of dental practice.