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


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.


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.


CDT - D4000-D4999 - see above.


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