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Policy No:  36E

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

Autogenous connective tissue graft (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position (D4273)

  • There are two surgical sites.  The recipient site utilizes a split thickness incision, retaining the overlapping flap of gingiva and/or mucosa. The connective tissue is dissected from a separate donor site leaving an epithelialized flap for closure.
  • Autogenous connective tissue graft (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site (D4283).
  • Site:  A term used to describe a single area, position, or locus.

Policy/criteria

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

Cosmetic exclusion applies.

Procedures includes donor site stent.

Administrative guidelines

Process to contract benefits.

Procedures may be subject to review by the dental consultant.

Codes

CDT - D4000-D4999 - see above

Disclaimer

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