Zip code - drawer
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Policy No:  36C

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


Pedicle soft tissue graft procedure (D4270)

A pedicle flap of gingiva can be raised from an edentulous ridge, adjacent teeth, or from the existing gingiva on the tooth and moved laterally or coronally to replace alveolar mucosa as marginal tissue. The procedure can be used to cover an exposed root or to eliminate a gingival defect if the root is not too prominent in the arch.


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

Procedures may be subject to review by the dental consultant.

Cosmetic exclusion applies for root coverage unless there is recession and minimal keratinized tissue.

One procedure benefit per tooth involved.

Separate charge for material costs is not a covered benefit.

Administrative guidelines

Process to contract benefits.


CDT - D4000-D4999 - see above


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