Free Soft Tissue Graft

Policy No: 36D
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

Free soft tissue graft procedure (including recipient and donor site surgery) (D4277, D4278)

  • Free soft tissue graft
    • First tooth, implant or edentulous tooth position (D4277)
    • Each additional contiguous tooth, implant or edentulous tooth position in same graft site (D4278)
  • Gingival or masticatory mucosa is grafted to create or augment the gingiva at another site, with or without root coverage. This graft may also be used to eliminate the pull of frena and muscle attachments, to extend the vestibular fornix, and to correct localized gingival recession. * Definition for the term "site" precedes code D4210.

Policy/criteria

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

Administrative guidelines

Process to contract benefits.

Procedures may be subject to review by the dental consultant.

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).

One benefit per 1-3 teeth pro rates for additional teeth (e.g. , 4 teeth = 1 and ½ benefit).

Codes

CDT - D4000-D4999 - see above.

Disclaimer

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