Periodontics Section - Free Soft Tissue Graft

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
Free soft tissue graft procedure (including donor site surgery) (D4271):

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.

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

Administrative Guidelines
Process to contract benefits.

Procedure is subject to review and requires a narrative and periodontal charting, including mucogingival condition:

1. Cosmetic exclusion applies.
2. Procedure includes donor site stent.
3. Procedure may be done using allograft or synthetic graft material – (separate charges for material costs is not a covered benefit).
4. One benefit per 1-3 teeth pro rated for additional teeth (e.g., 4 teeth = 1 and 1/2 benefit.

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