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    v1.0.30
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialWellpoint Biological Materials Coverage | OpenPaye…
    Ask Trek AI about this page
    ModifiedWellpointPolicy 04-203

    Biological Materials to Aid in Soft and Osseous Tissue Regeneration

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    This policy governs the documentation, clinical circumstances, and coding considerations for biological materials used alone or with other procedures to aid soft-tissue and osseous-tissue regeneration in dentistry. It applies to dental services, including regenerative treatment of periodontal defects involving natural teeth and dental implants, when covered under the applicable group contract.

    Policy Summary
    PayerWellpoint
    PolicyBiological Materials to Aid in Soft and Osseous Tissue Regeneration
    Policy CodePolicy 04-203
    Change TypeMinor editorial revision
    Effective Date01/01/2026
    Last ReviewOct 16, 2025
    Next Review DateN/A
    Key ActionDocument current, diagnostic-quality pretreatment periapical radiographic images obtained within 12 months.
    SourceLink
    POLICY UPDATE CHANGES

    The 2024 revision made minor editorial refinements to the description, clinical indications, and criteria.

    12 monthsMaximum documentation age
    6-pointPeriodontal charting format
    ≥5 mmMinimum pocket depth
    4 examplesBiological material examples

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Covered Use and Exclusions

    Documentation for covered use

    When covered by the specific group contract, indications for the use of biological materials must be documented by all of the following:

    Required clinical documentation

    • Pretreatment imaging: Current, diagnostic-quality pretreatment periapical radiographic images are documented.within 12 months
    • Post-initial-therapy periodontal measurements: Current, dated, post-initial-therapy six-point periodontal charting is documented and indicates minimum pocket depths of 5 mm.within 12 months; minimum pocket depth 5 mm
    • Procedure and material rationale: Rationale supporting the regeneration procedure and the type of biological material used is provided when requested.

      Examples include platelet-rich plasma (PRP), Emdogain, recombinant human bone morphogenic protein (rhBMP), and GEM 21S.

    Biological materials may not be considered when used in conjunction with soft-tissue grafting.

    Biological materials may not be considered when used in conjunction with bone grafts.

    Biological materials may not be considered when used in conjunction with guided tissue regeneration.

    Biological materials may not be considered when used in conjunction with ridge augmentation.

    Biological materials may not be considered when used in conjunction with periradicular surgery.

    Biological materials may not be considered when placed within extraction sites.

    Biological materials may not be considered when used with other regenerative materials.

    Procedure Codes and Documentation Parameters

    CDT procedure codesCPT
    D3431Biological materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery.
    CDT procedure codesCPT
    D4266Guided tissue regeneration - resorbable barrier per site
    Pretreatment periapical radiographs
    Required ageWithin 12 months
    Imaging typePretreatment periapical radiographic images
    Image standardCurrent and diagnostic quality
    Post-initial-therapy periodontal charting
    Required ageWithin 12 months
    Charting formatPost-initial-therapy 6-point periodontal charting
    Charting status

    Required Documentation and Provider Actions

    Documentation Required

    Submit current pretreatment radiographs

    Document current, diagnostic-quality pretreatment periapical radiographic images obtained within 12 months.

    Documentation Required

    Complete post-therapy periodontal charting

    Document current, dated, post-initial-therapy six-point periodontal charting obtained within 12 months. The charting must indicate minimum pocket depths of 5 mm.

    Documentation Required

    Support the procedure and material selection

    Provide rationale supporting the regeneration procedure and the type of biological material used when requested.

    • Examples include platelet-rich plasma (PRP), Emdogain®, recombinant human bone morphogenic protein (rhBMP), and GEM 21S®.

    Clinical Background

    Tissue engineering and regenerative medicine regenerate damaged tissue by developing biological substitutes that restore, maintain, or improve tissue function rather than relying on grafts such as autografts or allografts. In dentistry, biological materials may support adjunctive regenerative therapy for periodontal disease defects involving natural teeth and dental implants.

    Key Definitions

    Tissue engineering or regenerative medicine
    ProcessRegeneration of damaged tissues through development of biological substitutes
    PurposeRestore, maintain, or improve tissue function
    Alternative to graftsRegenerates tissue rather than using autografts or allografts
    Biological materials
    DefinitionMaterials used to aid regeneration of soft tissue and osseous tissue
    Clinical settingDental periodontal defects
    Implant-related useDefects involving dental implants
    Policy Summary
    PayerWellpoint
    PolicyBiological Materials to Aid in Soft and Osseous Tissue Regeneration
    Policy CodePolicy 04-203
    Change TypeMinor editorial revision
    Effective Date01/01/2026
    Last ReviewOct 16, 2025
    Next Review DateN/A
    Key ActionDocument current, diagnostic-quality pretreatment periapical radiographic images obtained within 12 months.
    SourceLink
    On This Page
    Covered Use and ExclusionsProcedure Codes and Documentation ParametersRequired Documentation and Provider ActionsClinical BackgroundKey Definitions
    Current and dated
    Periodontal pocket depth
    Minimum depth5 mm
    Measurement timingAfter initial therapy
    Documentation sourceSix-point periodontal charting
    Denial Risk

    Avoid disallowed combinations and sites

    The use of biological materials may not be considered when used in conjunction with the following procedures or sites:

    • Soft-tissue grafting
    • Bone grafts
    • Guided tissue regeneration
    • Ridge augmentation
    • Periradicular surgery
    • Placement within extraction sites
    • Other regenerative materials
    Denial Risk

    Verify contract coverage and supporting documentation

    Coverage consideration requires the applicable group contract to cover the service and the required clinical documentation to support the indication. Inclusion or exclusion of a procedure, diagnosis, or device code does not establish member coverage or provider reimbursement; refer to the member’s contract benefits in effect at the time of service.