CurrentEmpire BluecrossPolicy N/A

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.

Policy Summary

PayerEmpire Bluecross

PolicyDental Clinical Policy

Policy CodePolicy N/A

Change TypeClarified (annual review)

Effective DateJan 1, 2021

Next Review Date

Key ActionSubmit current dated 6-point periodontal charting indicating minimum 5 mm pocket depths as part of documentation when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Document revised (03-401 Revised) with annual review history entries through 12/4/2020.

1Primary CPT/CDT code listed

5Excluded conjoint procedures listed

2Required documentation items

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.

Documentation and Indications (when covered by specific group contract)

Documentation and Indications when covered by specific group contract

Indications for use must be documented by ALL of the following when covered by specific group contract:

ALL of the following

Periodontal charting: Current; dated periodontal charting (6-point periodontal charting as described by AAP and ADA) indicating a minimum of 5 mm pocket depths.minimum of 5 mm
Charting must be current and dated.
Pretreatment radiographs: Pretreatment periapical radiographic images that are of diagnostic quality, properly oriented, identified, and dated current.within 12 months
Letter of rationale: A letter of rationale explaining the necessity of the regeneration procedure and the type of material being used (examples: platelet rich plasma (PRP), Emdogain, recombinant human bone morphogenic protein (rhBMP), Gem-21S).
May be requested.
Exclusion circumstances (use MAY NOT be considered when ANY of the following apply)
- Soft tissue grafting: Used in conjunction with soft tissue grafting.
- Bone grafts: Used in conjunction with bone grafts.
- Guided tissue regeneration: Used in conjunction with guided tissue regeneration.
- Ridge augmentation: Used in conjunction with ridge augmentation.
- Periradicular surgery: Used in conjunction with periradicular surgery.

Provider Actions & Documentation Requirements

Documentation Required

Provide periodontal charting

Submit current dated 6‑point periodontal charting as described by AAP and ADA showing a minimum pocket depth of 5 mm when requesting coverage for biologic materials.

minimum 5 mm

Documentation Required

Provide diagnostic radiographs

Provide pretreatment periapical radiographic images of diagnostic quality that are properly oriented, identified, and dated current.

dated within 12 months

Documentation Required

Provide letter of rationale

Be prepared to submit a letter of rationale explaining the necessity of the regeneration procedure and specifying the type of biologic material to be used (examples include platelet rich plasma (PRP), Emdogain, recombinant human bone morphogenic protein (rhBMP), Gem-21S).

Denial Risk

Exclusion when used with other procedures or materials

Coverage may not be considered when biologic materials are used in conjunction with certain other procedures or materials. Review may result in denial when any of the following apply.

Used in conjunction with soft tissue grafting
Used in conjunction with bone grafts
Used in conjunction with guided tissue regeneration
Used in conjunction with ridge augmentation
Used in conjunction with periradicular surgery
Placed within extraction sites
Utilized with other regenerative materials

Background & Evidence

Background: The policy addresses biologic materials used alone or with other procedures to regenerate damaged dental tissues as an alternative to grafts, describing regenerative therapy applications for periodontal defects of natural teeth and dental implants. Utilization management review is performed because plan contracts may require that benefits meet specific contractual requirements and generally accepted standards of dental practice; a determination of medical or dental necessity does not guarantee plan coverage under a member's contract.

Selected references: Multiple peer-reviewed publications and American Academy of Periodontology (AAP) position/review papers are cited, including clinical studies and systematic reviews of enamel matrix derivatives and other biologic approaches (examples: Parodi R 2000; Giannobile W 2003; AAP Position Paper 2005) and additional randomized and histologic evaluations of regenerative materials and combinations (J Perio studies, J Clin Periodontol, Int J Perio Rest Dent).

Definition — Generally accepted standards of dental practice: includes specialty society recommendations/criteria, standards based on credible peer‑reviewed dental literature generally recognized by the practicing dental community, the views of recognized dentists practicing in the relevant clinical area, and other relevant factors from credible sources.

Revision History

2020-12-04review

Annual review documented (part of revision history entries through 12/4/2020).

2021-01-01effective_dateLatest

Document effective date published (01/01/2021); Document revised (03-401 Revised).

2017-02-08review

Earlier revision/annual review entries recorded in revision history.

Policy Summary

PayerEmpire Bluecross

PolicyDental Clinical Policy

Policy CodePolicy N/A

Change TypeClarified (annual review)

Effective DateJan 1, 2021

Next Review Date

Key ActionSubmit current dated 6-point periodontal charting indicating minimum 5 mm pocket depths as part of documentation when requesting coverage.

SourceLink

On This Page

OpenPayer

Dental Clinical Policy

Coverage Summary

Documentation and Indications (when covered by specific group contract)

Provider Actions & Documentation Requirements

Coding (informational)

Background & Evidence

Revision History