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    v1.0.30
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialWellpoint Bone Graft Coverage Update | OpenPayer
    Ask Trek AI about this page
    ModifiedWellpointPolicy 07-901

    Bone Grafts for Dental and Oral Surgical Services

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    Coverage review for bone graft procedures involving the jaw, maxilla, mandible, and oral/maxillofacial region, including documentation, medical necessity, and benefit eligibility.

    Policy Summary
    PayerWellpoint
    PolicyBone Grafts for Dental and Oral Surgical Services
    Policy CodePolicy 07-901
    Change TypeModified
    Effective Date01/01/2025
    Last ReviewOct 31, 2024
    Next Review DateN/A
    Key ActionSubmit current dated diagnostic pretreatment radiographs, a medical-necessity rationale, related-service information, and a recent health history when applicable.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    8Dental procedure codes listed
    12 monthsPretreatment radiograph recency
    3 monthsPostoperative management
    3 yearsSurgical re-entry
    3

    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.

    Listed causes of missing bone

    Clinical Coverage Criteria

    Clinical indication

    Bone grafts may be appropriate when replacing missing bone of the maxilla or mandible. At least one of the following causes must apply:

    Qualifying cause of missing bone

    • Cause: Congenital anomaly
    • Cause: Infection
    • Cause: Trauma

    Documentation for review

    Coverage consideration requires submission of supporting clinical information.

    Documentation requirements: The submitting dentist provides all clinical information related to the procedural request, including recent, dated, diagnostic pretreatment radiographic images; a letter of rationale explaining the medical necessity of the bone graft and whether it is related to another service; and a recent patient health history, if applicable.Pretreatment radiographs within 12 months

    Narrative and chart notes may also be required.

    Adjunctive procedures, including bone grafts and membranes, are not covered when the related primary procedure is not a covered service, even when the adjunctive procedure may be covered for other services.

    Bone grafting submitted with a coronectomy is not a covered benefit.

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

    Routine placement of a bone graft into an extraction site may not be medically necessary for complete and adequate healing.

    Coding and Service Parameters

    CDT codes including, but not limited to, the followingmixed
    D6100Implant removal, by report.
    D6103Bone graft for repair of peri-implant defect.
    D6104Bone graft at time of implant placement.
    D7295Harvest of bone for use in autogenous grafting procedure.
    D7950Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla; autogenous or non-autogenous, by report.
    D7951Sinus augmentation via a lateral open approach.
    D7952Sinus augmentation via a vertical approach.
    D7953Bone replacement graft for ridge preservation.
    D7955Repair of maxillofacial soft and/or hard tissue defect.
    ICD-10-CM Diagnoses for Dental Diseases and ConditionsICD-10
    No codes listed
    Pretreatment radiographic images
    RequirementCurrent, dated, diagnostic, pretreatment radiographic images
    RecencyObtained within 12 months
    Postoperative management
    Included periodImmediate three months following surgery
    Surgical re-entry
    Included periodAny surgical re-entry for three years, contract dependent

    Submission and Review Requirements

    Documentation Required

    Submit Clinical Information With the Request

    Submit all clinical information related to the bone graft procedural request with the request for review.

    Documentation Required

    Required Clinical Documentation

    Submitting dentists must provide a complete clinical information package supporting the requested bone graft and its medical necessity.

    • A letter of rationale explaining the necessity of the bone graft and whether it is related to another service.
    • A recent patient health history, if applicable.
    • Narrative and chart notes may be required.
    Documentation Required

    Pretreatment Radiographs Required

    Include current, dated, diagnostic pretreatment radiographic images with the request.

    Bone Grafting Overview

    Bone grafting adds bone tissue to the jaw to repair fractures, prepare a dental implant site, correct deformities, or restore or enhance oral and maxillofacial structure and function. Grafts may be appropriate when bone is missing from the maxilla or mandible because of a congenital anomaly, infection, or trauma.

    Policy Summary
    PayerWellpoint
    PolicyBone Grafts for Dental and Oral Surgical Services
    Policy CodePolicy 07-901
    Change TypeModified
    Effective Date01/01/2025
    Last ReviewOct 31, 2024
    Next Review DateN/A
    Key ActionSubmit current dated diagnostic pretreatment radiographs, a medical-necessity rationale, related-service information, and a recent health history when applicable.
    SourceLink
    On This Page
    Clinical Coverage CriteriaCoding and Service ParametersSubmission and Review RequirementsBone Grafting Overview
    • Images must be current, meaning obtained within 12 months of the request.
    • Radiographs must be dated, diagnostic, and obtained before treatment.
    Denial Risk

    Assess Healing Risk

    Assess medical and behavioral factors that could compromise healing before proceeding with or requesting a bone graft.

    • Medical complications or contraindications must be considered.
    • Document poor oral hygiene when present.
    • Consider habits that may compromise healing, including smoking cigarettes or cigars.
    Denial Risk

    Primary Service Must Be Covered

    When the primary procedure is not a covered service, related adjunctive procedures are not covered benefits, even when the plan covers those procedures for other services.

    • This includes bone grafts and the use of membranes when they are related to a non-covered primary service.
    Denial Risk

    Endodontic and Minor Periradicular Grafting

    Bone graft procedures associated with endodontic therapies or minor periradicular surgery may not be a covered benefit because bone typically heals by secondary intention.

    Denial Risk

    Coronectomy-Associated Grafting Not Covered

    Bone grafting submitted with a coronectomy is not a covered benefit.

    Denial Risk

    Routine Extraction-Site Grafting

    Routine placement of a bone graft into an extraction site may not be necessary for complete and adequate healing; coverage should not be assumed.

    Billing Rule

    Verify Coverage for Major Reconstructive Grafts

    For major reconstructive bone graft procedures, check the patient’s medical plan for coverage before submission or treatment.