Audience
Zip code - drawer
County - drawer

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Policy No:  36F

Originally Created: 01/01/2000

Section: Periodontics

Last Reviewed:  01/01/2019

Last Revised:  01/01/2018

Approved: 01/01/2018

Effective:  01/01/2018

Description

Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) (D4274)

This procedure is performed in an edentulous area adjacent to a periodontally involved tooth. Gingival incisions are utilized to allow removal of a tissue wedge to gain access and correct the underlying osseous defect and to permit close flap adaptation.

Policy/criteria

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

Procedures may be subject to review by the dental consultant.

This is a one-tooth benefit.

No benefit if done with D4210, D4240, D4260 in same quadrant.

If no evidence of bone loss, benefit D4211 or pro rated D4240.

Administrative guidelines

Process to contract benefits.

Codes

CDT - D4000-D4999 - see above

Disclaimer

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