ModifiedEmpire BluecrossPolicy 07-901

Bone Grafts for Dental and Oral Surgical Services

This policy governs clinical appropriateness and review requirements for bone grafting and bone substitute materials used with dental and oral surgical procedures for members covered by the plan.

Policy Summary

PayerEmpire Bluecross

PolicyBone Grafts for Dental and Oral Surgical Services

Policy CodePolicy 07-901

Change TypeRoutine review — no material changes

Effective Date

Next Review DateJan 1, 2024

Key ActionSubmit clinical documentation including recent dated radiographs, a letter of rationale, recent health history, and periodontal chart when requesting review for bone grafting.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CDT 2024coding reference edition

Requiredclinical review

Radiographs ≤12moimaging recency

3 monthspost-op follow-up

Coverage Criteria for Bone Grafts

inv-01: Medically Necessary Criteria 6 Bone grafting is considered appropriate when ALL of the following are met

Policy Summary

PayerEmpire Bluecross

PolicyBone Grafts for Dental and Oral Surgical Services

Policy CodePolicy 07-901

Change TypeRoutine review — no material changes

Effective Date

Next Review DateJan 1, 2024

Key ActionSubmit clinical documentation including recent dated radiographs, a letter of rationale, recent health history, and periodontal chart when requesting review for bone grafting.

SourceLink

On This Page

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Primary clinical indications: Replacement of missing bone of the maxilla or mandible due to congenital anomalies, infection, or trauma

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Documentation: Submission includes current (within 12 months), dated diagnostic pretreatment radiographic images; a letter of rationale explaining the necessity of the bone graft and relation to other services; recent patient health history; and a recent dated periodontal chart if applicable; narrative and chart notes may be required

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Patient factors considered: Patient has been evaluated for medical complications or contraindications and for factors that compromise healing (e.g., poor oral hygiene, smoking); these must be considered prior to proceeding

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Postoperative management and re-entry: Post-operative management for bone procedures is included for the immediate three months following surgery; surgical re-entry related to the graft is considered for up to three years (group contract dependent)

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Payer coordination for major reconstructive procedures: For major bone (reconstructive) procedures, the patient’s medical plan should be checked for coverage prior to proceeding

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inv-02: Not Medically Necessary / Non-covered Situations 6 Bone grafts are not considered a covered benefit when ANY of the following apply

Bone grafts are not considered a covered benefit when ANY of the following apply

Primary procedure not covered: If the primary procedure is not a covered service, all related adjunctive procedures including bone grafts and membranes are not covered

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Endodontic or minor periradicular surgery: Bone graft procedures associated with endodontic therapies or minor periradicular surgery may not be benefitted because bone typically heals by secondary intention

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

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Codes and Coding Guidance

Covered CDT Codes (examples listed)CDTCovered

D6100	Implant removal, by report
D6103	Bone for repair of peri-implant defect graft
D6104	Bone at time of implant placement graft
D7295	Harvest of bone for use in autogenous grafting procedure
D7950	Osseous, osteoperiosteal, or cartilaginous graft, autogenous or non-autogenous, by report
D7951	Sinus augmentation via a lateral open approach
D7952	Sinus augmentation via a vertical approach
D7953	Bone replacement for ridge preservation graft
D7955	Repair of maxillofacial soft and/or hard tissue defect

Diagnosis coding guidanceICD-10

ICD-10

ICD-10 CM Diagnoses for Dental Diseases and Conditions: See the current CDT code book for details

Provider Requirements and Authorization

Prior Authorization

Prior Authorization / Clinical Review

Requests for bone grafting procedures may be reviewed for appropriateness by dental professionals. Submitting dentists must include all pertinent clinical information related to the procedural request.

Recent, dated diagnostic pretreatment radiographic images (current within 12 months).
Letter of rationale explaining medical necessity of the bone graft and whether it is related to another service.
Recent patient health history and recent dated periodontal chart, if applicable.
Narrative and chart notes may be required to support medical necessity.
Bone procedures include post-operative management for the immediate three months following surgery and for any surgical re-entry for three years (group contract dependent).
For major reconstructive bone procedures, verify the patient’s medical plan for possible coverage.
Patients with medical complications or contraindications, poor oral hygiene, or habits that compromise healing (for example, smoking) must be considered when evaluating appropriateness.

Denial Risk

Adjunctive Procedures Related to Non‑Covered Primary Service

When the primary procedure is not a covered service, all related adjunctive procedures are also not covered even if they are otherwise covered by the plan for other services.

Adjunctive procedures related to a non-covered primary service include, but are not limited to, bone grafts and use of membranes.
Bone grafts associated with endodontic therapies or minor periradicular surgery may not be a benefit, as bone often heals by secondary intention.
Routinely placing bone grafts into extraction sites may not be necessary for complete and adequate healing.

Documentation Required

Required Documentation for Review

Required documentation for review — Submitting dentists must supply pertinent clinical documentation to support the request for bone grafting procedures.

Current (within 12 months), dated diagnostic pretreatment radiographic images.
Letter of rationale describing the clinical indication and relationship to any other procedure.
Recent patient health history and any relevant medical documentation of complications or contraindications.
Recent dated periodontal chart, if applicable.
Narrative operative and chart notes and any other documentation requested during review.

Billing Rule

Provider Action and Denial Risk Highlights

Provider action / denial risk — be aware of coverage limitations and documentation expectations when submitting requests for bone procedures.

Verify benefit coverage for major reconstructive bone procedures with the patient’s medical plan when appropriate.
Failure to submit required documentation may result in denial or delay of review.
Bone graft-related post-operative care timeframes (3 months immediate; up to 3 years for surgical re-entry) may affect benefit determination per group contract.

Background

Bone grafting replaces missing bone of the maxilla or mandible that may result from congenital anomalies, infection, or trauma. The plan evaluates bone graft procedures against generally accepted standards of dental practice and requires appropriate clinical documentation and consideration of patient factors (for example, medical complications, contraindications, poor oral hygiene, or habits such as smoking) before determining that the procedure is appropriate.

Definitions and Standards

Generally accepted standards of dental practice

DefinitionStandards based on credible scientific evidence published in peer‑reviewed dental literature, the views of recognized practicing dentists, specialty society recommendations/criteria, and other relevant credible sources.

PurposeGuide dental services that a dentist, exercising prudent clinical judgment, provides to evaluate, diagnose, or treat a dental injury or disease and its symptoms.

Scope of careCare must be in accordance with generally accepted standards of dental practice in terms of type, frequency, and extent and be considered effective for the patient’s dental injury or disease.

ExclusionsServices performed primarily for patient or dentist convenience, cosmetic procedures, or those more costly than an alternative service are not consistent with generally accepted standards.

Clinical components requiredStandards incorporate peer‑reviewed evidence, practicing clinicians’ views, and specialty society recommendations to determine appropriateness of dental procedures (e.g., bone grafting).