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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


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.


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.


CDT - D4000-D4999 - see above


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