ModifiedUnitedHealthcarePolicy DCP045.09

Dental Barrier Membrane Guided Tissue Regeneration

Defines clinical indications, contraindications, applicable CDT procedure codes, clinical evidence summary, and guidance for use of resorbable and non-resorbable barrier membranes in guided tissue/bone regeneration for UnitedHealthcare dental plans. It is informational and requires member-specific benefit plan documents to determine actual coverage.

Policy Summary

PayerUnitedHealthcare

PolicyDental Barrier Membrane Guided Tissue Regeneration

Policy CodePolicy DCP045.09

Change TypeUpdated clinical evidence and references

Effective DateMay 1, 2025

Next Review Date

Key ActionDocument clinical indication, defect morphology, prognostic assessment, systemic contraindications, and report the appropriate CDT code to support use of a barrier membrane.

POLICY UPDATE CHANGES

Supporting Information Updated Clinical Evidence and References sections to reflect the most current information; archived previous policy version DCP045.08

8Applicable CDT Codes

8Indicated Clinical Situations

8Contraindications / Not Indicated

Coverage Summary

Overview: This policy (Policy Number: DCP045.09) addresses the use of resorbable and non‑resorbable dental barrier membranes for guided tissue/bone regeneration. The stance on coverage is mixed — indications and use are described, but evidence and coverage conclusions vary by clinical situation and the member’s benefit plan. Effective date: 2025-05-01. Last review: 2025-05-01.

Medical-Necessity Criteria

Indications for Guided Tissue Regeneration (GTR)

GTR is indicated for the following clinical situations:

Infrabony vertical defects (intrabony defects)

Class II furcation involvements

Ridge preservation

In conjunction with bone grafting for ridge augmentation or reconstruction

In conjunction with bone grafting for treatment of peri-implant defects

Implant placement (when indicated in conjunction with grafting/regeneration)

To enhance periodontal tissue regeneration and healing for mucogingival defects in conjunction with mucogingival surgeries

Not Indicated / Contraindications

GTR is not indicated for individuals or defects meeting any of the following:

Individuals with an uncontrolled underlying medical condition (including but not limited to metabolic, cardiovascular, autoimmune/inflammatory, or genetic conditions that affect collagen synthesis)

Teeth with a poor or hopeless prognosis

Individuals taking medications that negatively affect healing (including but not limited to immunosuppressive agents, corticosteroids, anticoagulants, NSAIDs, and nicotine)

Individuals with poor oral hygiene

Individuals who have been non-compliant with previous therapies

Osseous defects with less than two walls

Applicable Procedure Codes (CDT)

Applicable CDT procedure codes (for reference)CPT

D6106	Guided tissue regeneration resorbable barrier; per implant
D6107	Guided tissue regeneration non-resorbable barrier; per implant
D3432	Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery
D4266	Guided tissue regeneration, natural teeth resorbable barrier, per site
D4267	Guided tissue regeneration, natural teeth non-resorbable barrier, per site
D4286	Removal of non-resorbable barrier
D7956	Guided tissue regeneration, edentulous area resorbable barrier, per site
D7957	Guided tissue regeneration, edentulous area non-resorbable barrier, per site

Provider Actions & Billing Guidance

Documentation Required

Confirm indication and defect morphology

Document the clinical indication (e.g., infrabony defect, Class II furcation, ridge preservation, peri-implant defect), the defect morphology (number of walls), and a prognostic assessment to support use of a barrier membrane.

D4266
D4267
D6106
D6107
D7956
D7957
D3432

Documentation Required

Assess contraindications and systemic factors

Document absence of uncontrolled medical conditions, medications that negatively affect healing, active poor oral hygiene, history of non‑compliance, and the tooth prognosis before performing GTR.

Billing Rule

Use appropriate CDT code per site and membrane type

Report the specific CDT procedure code that corresponds to membrane type (resorbable vs non‑resorbable), the clinical site (natural tooth, implant, edentulous area), and the procedure context (e.g., periradicular surgery) when billing.

D6106
D6107
D3432
D4266
D4267
D7956
D7957

Documentation Required

Removal of non-resorbable membrane

If a non‑resorbable barrier membrane is used and later removed, document the membrane removal and bill using D4286 when removal is performed.

D4286

Background & Evidence Summary

Background: Barrier membranes are used to exclude epithelium and soft tissue from bone regeneration sites to promote new bone, cementum, and periodontal ligament formation. Membranes may be resorbable (natural collagen or synthetic aliphatic polyesters such as PLGA) or non‑resorbable (expanded or dense PTFE and related materials). They are intended for procedures including augmentation/reconstruction of alveolar ridge defects, ridge preservation, treatment of peri‑implant defects, and to support periodontal regeneration in specified defect types. Clinical evidence is mixed: some trials and systematic reviews report benefits for specific defect morphologies and procedures (for example, improved defect fill in certain augmentation and Grade II furcation treatments), while other reviews note limited trial sizes, heterogeneity, and risk of bias that limit definitive conclusions; in vitro data show PTFE membranes act as barriers to bacterial passage though biofilm accumulation differs by membrane microstructure.

Evidence Item	Key Finding/Value
Long-term implant survival (Jung et al. 2021)	89.3% to 93.8% for augmented and nonaugmented sites over ~23.5 years
Benefit in Grade II furcation defects (Swami et al. 2021)	Supplemental benefits of BRG + GTR vs BRG or OFD; SMDs reported for VDF, HDF, and CAL gains
Alveolar ridge preservation (Avila-Ortiz et al. 2019)	ARP via socket grafting prevents horizontal and vertical bone resorption vs extraction alone; particulate xenogenic/allogenic + membrane associated with favorable outcomes
ePTFE vs d-PTFE biofilm (Trobos et al. 2018)	d-PTFE had greater biofilm biomass and viable S. oralis vs e-PTFE in vitro; all membranes impermeable to S. oralis
Membrane use in implant/augmentation procedures (Merli et al. 2016; Jonker et al. 2016)	Some studies show greater vertical/horizontal bone fill with membranes (e.g., 1.64 mm vertical benefit); overall evidence limited by small trials, heterogeneity, and bias
Overall quality of evidence	Multiple systematic reviews note limited trial sizes, heterogeneity, and risk of bias limiting definitive conclusions

Definitions

Guided Tissue Regeneration (GTR): A surgical procedure aiming to achieve new bone, cementum, and PDL attachment using barrier membranes to provide space maintenance, epithelial exclusion, and wound stabilization.

Ridge Preservation (ARP): Surgical procedure to prevent ridge collapse and preserve alveolar ridge dimensions after tooth extraction, often using grafts and membranes.

Furcation: Anatomic area of a multirooted tooth where the roots diverge; furcation involvement refers to loss of periodontal support in that area.

Policy Summary

PayerUnitedHealthcare

PolicyDental Barrier Membrane Guided Tissue Regeneration

Policy CodePolicy DCP045.09

Change TypeUpdated clinical evidence and references

Effective DateMay 1, 2025

Next Review Date

Key ActionDocument clinical indication, defect morphology, prognostic assessment, systemic contraindications, and report the appropriate CDT code to support use of a barrier membrane.

On This Page

OpenPayer

Dental Barrier Membrane Guided Tissue Regeneration

Coverage Summary

Medical-Necessity Criteria

Applicable Procedure Codes (CDT)

Provider Actions & Billing Guidance

Background & Evidence Summary

Revision History