Combined Connective Tissue and Double Pedicle Graft

Policy No: 36H
Originally Created: 01/01/2011
Section: Periodontics
Last Reviewed: 01/01/2019
Last Revised: 01/01/2018
Approved: 01/01/2018
Effective: 01/01/2018

Description

Combined connective tissue and double pedicle graft (D4276)
Advanced gingival recession often cannot be corrected with a single procedure. Combined tissue grafting procedures are needed to achieve the desired outcome.

Policy/criteria

Procedures are in accordance with generally accepted standards of dental practice.

Cosmetic exclusion applies.

Procedure includes donor site stent.

Procedure may be done using allograft or synthetic graft material – (separate charges for material costs is not a covered benefit).

Isolated deep recession in the presence of a mucogingival defect.

Administrative guidelines

Process to contract benefits.

Codes

CDT - D4000-D4999 - see above.

Disclaimer

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