Surgical Revision Procedure, per Tooth

Policy No: 36B
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

Surgical revision procedure, per tooth (D4268)
This procedure is to refine the results of a previously provided surgical procedure. This may require a surgical procedure to modify the irregular contours of hard or soft tissue. A mucoperiosteal flap may be elevated to allow access to reshape alveolar bone. The flaps are replaced or repositioned and sutured.

Policy/criteria

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

Must be over 3 years since the first procedure by the same dentist.

Procedure may be subject to review by the dental consultant.

Administrative guidelines

Process to contract benefits, by report.

Codes

CDT - D4000-D4999 - see above.

Disclaimer

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