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    v1.0.30
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialWellPoint Guided Tissue Policy Update | OpenPayer
    Ask Trek AI about this page
    CurrentWellPointPolicy 04-209

    Guided Tissue Regeneration

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    This policy governs clinical indications, documentation, coverage limitations, and coding for guided tissue regeneration procedures in dental and oral/maxillofacial care. Coverage is subject to the member’s contract, and federal or state law and contract language take precedence.

    Policy Summary
    PayerWellPoint
    PolicyGuided Tissue Regeneration
    Policy CodePolicy 04-209
    Change TypeMinor editorial revision
    Effective Date01/01/2026
    Last ReviewOct 28, 2025
    Next Review DateN/A
    Key ActionSubmit current pretreatment radiographs and post-initial-therapy 6-point periodontal charting documenting pocket depths of at least 5 mm.
    SourceLink
    POLICY UPDATE CHANGES

    Minor editorial refinements were made without changing policy intent.

    5 mmMinimum periodontal pocket depth
    12 monthsMaximum age of radiographs and charting
    5CDT procedure codes listed
    3 monthsPostoperative management included

    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.

    3 years
    Surgical re-entry period included
    Class IIPotential furcation indication

    Coverage Criteria and Limitations

    Clinical indications and documentation

    Guided tissue regeneration may be appropriate when the clinical indication and documentation requirements below are met, subject to contract terms.

    Covered clinical use and documentation

    • Potential clinical indications: The defect involves Class II furcation involvement, a vertical intrabony or infrabony defect, or adjunctive use with bone grafting.

      The procedure should generally be confined to vertical, multi-walled or narrow defects with areas of vertical bone loss or Class II furcation defects.

    • Required periodontal documentation

      • Pretreatment radiographs: All associated diagnostic radiographs are dated within 12 months, properly oriented, obtained before treatment, and demonstrate vertical bone defects.Within 12 months

        Required for periodontal purposes.

      • Post-initial-therapy periodontal charting: Current dated 6-point periodontal charting performed after initial therapy demonstrates pocket depths of at least 5 mm.Minimum pocket depth 5 mm; 6-point charting; within 12 months

    Contract-dependent and reconstructive procedures

    Additional coverage conditions and limitations

    Procedure setting and associated services

    • Permitted defect setting: The treatment addresses a periodontal defect or a peri-implant defect.

      Coverage is contract dependent.

    • Implant association: The procedure is performed in conjunction with a dental implant when the contract allows the benefit.

      Coverage is contract dependent.

    Guided tissue regeneration procedures associated with endodontic therapies or minor periradicular surgery are typically not a covered benefit because the bone is expected to heal by secondary intention.

    Guided tissue regeneration is not considered for benefits when performed in conjunction with soft tissue grafting procedures.

    Biologic materials used for soft or osseous tissue regeneration are not considered for benefits when used in conjunction with guided tissue regeneration.

    Routine guided tissue regeneration for extraction sites may not be necessary to achieve complete and adequate healing.

    Coding and Documentation Requirements

    CDT including but not limited tomixed
    D3432Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery
    D4266Guided tissue regeneration - resorbable barrier, per site
    D4267Guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal)
    D7956Guided tissue regeneration, edentulous area - resorbable barrier, per site
    D7957Guided tissue regeneration, edentulous area - non-resorbable barrier, per site
    ICD-10-CM Diagnoses for Dental Diseases and ConditionsICD-10
    No codes listed
    Diagnostic documentation currency
    Required currencyDiagnostic radiographs and periodontal charting must be current within 12 months.
    Radiograph timingDiagnostic radiographs must be dated within 12 months and obtained before treatment.
    Charting timingPeriodontal charting must be current, dated within 12 months, and performed after initial therapy.
    Periodontal pocket-depth requirement
    Minimum pocket depthPeriodontal pocket depths must be at least 5 mm.
    Required chartingThe pocket-depth measurement must be documented on post-initial-therapy 6-point periodontal charting.

    Provider Submission and Verification Actions

    Note

    Check the Medical Plan

    For major guided tissue regeneration or reconstructive procedures, check the patient’s medical plan for applicable coverage before proceeding.

    Billing Rule

    Verify Contract-Dependent Benefits

    Verify the member’s contract-specific benefits before submitting guided tissue regeneration claims for periodontal, peri-implant, or implant-associated procedures.

    Unsupported block type: documentation

    Unsupported block type: documentation

    Clinical Background

    Guided tissue regeneration is a surgical procedure used to promote new bone, cementum, and periodontal ligament attachment to a periodontally diseased tooth. It may be appropriate for Class II furcation involvement, vertical intrabony or infrabony defects, or adjunctive use with bone grafting. Treatment should generally be confined to vertical, multi-walled or narrow defects with areas of vertical bone loss or Class II furcation defects.

    Definitions

    Guided tissue regeneration
    ProcedureGuided tissue regeneration is a surgical procedure.
    Intended attachmentThe procedure is used to achieve new bone, cementum, and periodontal ligament (PDL) attachment.
    Treatment contextThe intended attachment is to a periodontally diseased tooth.
    Class II furcation involvement
    Defect locationClass II furcation involvement consists of a periodontal defect involving the furcation area of a tooth.
    ClassificationThe involvement is classified as Class II.
    Clinical relevance
    Policy Summary
    PayerWellPoint
    PolicyGuided Tissue Regeneration
    Policy CodePolicy 04-209
    Change TypeMinor editorial revision
    Effective Date01/01/2026
    Last ReviewOct 28, 2025
    Next Review DateN/A
    Key ActionSubmit current pretreatment radiographs and post-initial-therapy 6-point periodontal charting documenting pocket depths of at least 5 mm.
    SourceLink
    On This Page
    Coverage Criteria and LimitationsCoding and Documentation RequirementsProvider Submission and Verification ActionsClinical BackgroundDefinitions
    Documentation currencyThe periodontal charting must be current and dated within 12 months.
    Post-initial-therapy periodontal charting
    Charting typeSix-point periodontal charting is required.
    TimingCharting must be performed after initial therapy.
    Required findingThe charting must indicate periodontal pocket depths of a minimum of 5 mm.
    Denial Risk

    Endodontic or Periradicular Association

    Guided tissue regeneration associated with endodontic therapy or minor periradicular surgery is typically not a covered benefit because the bone heals by secondary intention.

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: info

    Unsupported block type: billing_rule

    Class II furcation involvement is identified as a potential indication for guided tissue regeneration.
    Vertical defect
    DefinitionA vertical defect is an intrabony or infrabony defect.
    Relevant characteristicsThe defect is particularly relevant when it is multi-walled or narrow.
    Bone-loss patternRelevant defects have areas of vertical bone loss and are among the defects to which guided tissue regeneration should generally be confined.