Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyWellpoint Bone Graft Coverage Update | OpenPayer
    Ask Trek AI about this page
    ModifiedWellpointPolicy 07-901

    Bone Grafts for Dental and Oral Surgical Services

    Customize your policy alerts

    Sign up for wellpoint Policy 07-901 alerts

    Get alerted when Policy 07-901 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This guideline governs coverage review, clinical criteria, documentation, and coding for bone grafting and related grafting procedures involving the jaw, maxilla, mandible, implant sites, and oral or maxillofacial defects. It applies to submitting dentists and is subject to the member’s benefit plan, contract terms, and applicable law.

    Policy Summary
    PayerWellpoint
    PolicyBone Grafts for Dental and Oral Surgical Services
    Policy CodePolicy 07-901
    Change TypeMinor editorial refinementsno material clinical or coverage change
    Effective Date01/01/2026
    Last ReviewOct 30, 2025
    Next Review DateN/A
    Key ActionProvide current, dated, diagnostic pretreatment radiographic images obtained within 12 months of the request.
    SourceLink
    POLICY UPDATE CHANGES

    The revision history identifies the October 31, 2024 revision as minor editorial refinements to the description and clinical content.

    12 monthsMaximum age of required pretreatment diagnostic radiographs
    3 monthsImmediate postoperative management included after graft surgery
    3 yearsPeriod for included surgical re-entry, contract dependent
    16CDT codes listed in the coding section

    Clinical Coverage and Benefit Limitations

    Clinical indications and submission requirements

    Bone grafts may be appropriate when replacing missing bone of the maxilla or when bone loss results from congenital anomalies, infection, or trauma, subject to documentation and benefit limitations.

    Clinical appropriateness and submission requirements

    • Clinical indication

      • Missing bone of the maxilla is documented.
      • Bone loss resulting from a congenital anomaly, infection, or trauma is documented.
      • The request concerns repair of a fracture, implant-site preparation, correction of a deformity, or restoration or enhancement of oral and maxillofacial structure and function.
    Policy Summary
    PayerWellpoint
    PolicyBone Grafts for Dental and Oral Surgical Services
    Policy CodePolicy 07-901
    Change TypeMinor editorial refinementsno material clinical or coverage change
    Effective Date01/01/2026
    Last ReviewOct 30, 2025
    Next Review DateN/A
    Key ActionProvide current, dated, diagnostic pretreatment radiographic images obtained within 12 months of the request.
    SourceLink
    On This Page
    Clinical Coverage and Benefit LimitationsCoding and Service TimingSubmission and Documentation RequirementsBone Grafting Overview

    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.

    Supporting documentation:
    Current, dated, diagnostic pretreatment radiographs, a rationale letter addressing the necessity of the graft and whether it is related to another service, and a recent patient health history when applicable are submitted.
    Radiographs within 12 months

    Submitting dentists must provide all clinical information related to the request. Narrative and chart notes may also be required.

  1. Risk and healing assessment: Medical complications or contraindications, oral hygiene, and healing-compromising habits such as cigarette or cigar smoking are considered.

    2. Benefit and related-service limitations

    Benefit treatment and related services are subject to the following limitations.

    Benefit and service relationship limitations

    • Included service period

      • Postoperative management is included for the immediate three months following surgery.Immediate three months following surgery
      • Surgical re-entry is included for three years, contract dependent.Three years; contract dependent

    • Primary service coverage

      • The primary procedure is a covered service.
      • The request concerns a major reconstructive graft evaluated under the applicable medical plan.

        Major reconstructive bone graft procedures may be covered under the member's medical plan rather than the dental benefit.

    • Related-service limitations: When the primary procedure is not a covered service, related adjunctive procedures, including bone grafts and membranes, are not covered even if the adjunctive procedure would otherwise be covered for other services.
    • Specific service limitations: 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; and routine placement of bone grafts into extraction sites may not be necessary for complete and adequate healing.

    Related adjunctive procedures, including bone grafts and membranes, are not covered when the primary procedure is not a covered service, even if the adjunctive procedure would otherwise be covered for other services.

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

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

    Major reconstructive bone graft procedures may be covered under the member’s medical plan rather than the dental benefit. Coverage is subject to the applicable medical plan terms.

    Routine placement of bone grafts into extraction sites may not be necessary for complete and adequate healing.

    Coding and Service Timing

    CDT Including but not limited toCPT
    D6100Implant removal, by report
    D6103Bone graft for repair of peri-implant defect
    D6104Bone graft at time of implant placement
    D6105Removal of implant body not requiring bone removal or flap elevation
    D6106Guided Tissue Regeneration (Implant Site, Resorbable Barrier)
    D6107Guided Tissue Regeneration (Implant Site, Non-Resorbable Barrier)
    D7295Harvest of bone for use in autogenous grafting procedure
    D7921Collection and application of autologous blood concentrate product
    D7922Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site
    D7950Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla autogenous or non-autogenous, by report
    1–10 of 16
    1/2
    Pretreatment radiograph age
    RequirementPretreatment radiographic images must be current within 12 months.
    Postoperative management
    Included periodPostoperative management is included for the immediate three months following surgery.
    Surgical re-entry
    Included periodSurgical re-entry is included for three years, contract dependent.

    Submission and Documentation Requirements

    Documentation Required

    Submit complete clinical support

    Submitting dentists must include any and all clinical information related to the procedural request, including recent, dated radiographic images, a letter of rationale explaining the necessity of the bone graft and whether it is related to another service, and a recent patient health history, if applicable. Narrative and chart notes may also be required.

    Documentation Required

    Include current pretreatment radiographs

    Provide current, dated, diagnostic pretreatment radiographic images obtained within 12 months of the request.

    Documentation Required

    Document healing risks

    The clinical submission must address medical complications or contraindications, oral hygiene, and habits that compromise healing, such as smoking cigarettes or cigars.

    Denial Risk

    Verify primary procedure coverage

    Related adjunctive procedures, including bone grafts and membranes, are not covered when the primary procedure is not a covered service, even if the adjunctive procedure would otherwise be covered for other services.

    Denial Risk

    Coronectomy-associated grafting is excluded

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

    Denial Risk

    Endodontic and minor periradicular cases may not be covered

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

    Denial Risk

    Avoid routine extraction-site grafting

    Routinely placing bone grafts into extraction sites may not be necessary for complete and adequate healing.

    Bone Grafting Overview

    Bone grafting is a surgical procedure that adds bone tissue to the jaw or related oral and maxillofacial structures. It may be used to replace missing maxillary or mandibular bone associated with congenital anomalies, infection, trauma, fractures, deformities, implant-site preparation, or restoration and enhancement of oral and maxillofacial structure and function.