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Policy No:  36G

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

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).

Policy/criteria

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.

Administrative guidelines

Process to contract benefits.

Procedures may be subject to review by the dental consultant.

Codes

CDT - D4000-D4999 - see above

Disclaimer

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