Audience
Zip code - drawer
County - drawer

Sign in

Sign in

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

Description

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.

Policy/criteria

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.

Codes

CDT - D4000-D4999 - see above

Disclaimer

Your use of this Dental Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Dental Policy Disclaimer.