Periodontics Section - Apically Positioned Flap

IMPORTANT INFORMATION This Dental Policy has been developed through consideration of generally accepted standards of dental practice, review of dental literature, dental necessity, and as appropriate, government approval. Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. The purpose of dental policy is to provide a guide to coverage. Dental policy is not intended to dictate to providers how to practice dentistry. Providers are expected to exercise their clinical judgment in providing the most appropriate care.

Description
Apically positioned flap (D4245):

Procedure is used to preserve keratinized gingiva in conjunction with osseous resection and second stage implant procedure. Procedure may also be used to preserve keratinized/attached gingiva during surgical exposure of labially impacted teeth, and may be used during treatment of peri-implantitis.

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

Procedure is considered inclusive of D7280 and D7281.

Procedure is subject to review by the dental consultant and requires documentation for determination of benefit estimate or claims payments including:

1. Current periodontal charting and radiographs of the area involved.
2. A narrative when documentation does not demonstrate necessity.
3. No benefit with osseous surgery (D4260, D4261 or D4240).

Administrative Guidelines
Process to contract benefits.

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