Non-autogenous Connective Tissue Graft

Policy No: 36G
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

Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft (D4275)
There is only a recipient surgical site utilizing split thickness incision, retaining the overlaying flap of gingiva and/or mucosa. A donor surgical site is not present. Non-autogenous connective tissue graft (including recipient site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site (D4285).

Policy/criteria

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

Cosmetic exclusion applies.

Procedure may be done using non-autogenous graft material.

Note: Material costs are included in procedure.

Administrative guidelines

Process to contract benefits.

Procedures may be subject to review by the dental consultant.

Codes

CDT - D4000-D4999 - see above

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