Policy No: 36G
Originally Created: 01/01/2011
Last Reviewed: 01/01/2019
Last Revised: 01/01/2018
Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft (D4275)
There is only a recipient surgical site utilizing split thickness incision, retaining the overlaying flap of gingiva and/or mucosa. A donor surgical site is not present. Non-autogenous connective tissue graft (including recipient site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site (D4285).
Procedures are in accordance with generally accepted standards of dental practice.
Cosmetic exclusion applies.
Procedure may be done using non-autogenous graft material.
Note: Material costs are included in procedure.
Process to contract benefits.
Procedures may be subject to review by the dental consultant.
CDT - D4000-D4999 - see above
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