Policy No: 36D
Originally Created: 01/01/2011
Last Reviewed: 01/01/2019
Last Revised: 01/01/2018
Free soft tissue graft procedure (including recipient and donor site surgery) (D4277, D4278)
Free soft tissue graft
- First tooth, implant or edentulous tooth position (D4277)
- Each additional contiguous tooth, implant or edentulous tooth position in same graft site (D4278)
- Gingival or masticatory mucosa is grafted to create or augment the gingiva at another site, with or without root coverage. This graft may also be used to eliminate the pull of frena and muscle attachments, to extend the vestibular fornix, and to correct localized gingival recession. * Definition for the term "site" precedes code D4210.
Procedures are in accordance with generally accepted standards of dental practice.
Process to contract benefits.
Procedures may be subject to review by the dental consultant.
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).
One benefit per 1-3 teeth pro rates for additional teeth (e.g. , 4 teeth = 1 and ½ benefit).
CDT - D4000-D4999 - see above
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.