Periodontics Section - Subepithelial Connective 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
Subepithelial connective tissue graft (including donor site) (D4273):

This procedure is performed to create or augment gingiva, to obtain root coverage or to eliminate sensitivity and to prevent root caries, to eliminate frenum pull, or to extend the vestibular fornix. The recipient site utilizes a split thickness incision but retains the overlying flap of gingiva and/or mucosa. The connective tissue graft is dissected from the donor site leaving an epithelialized flap for closure. The donor tissue is placed at the recipient site and sutured into position. The graft is covered with the overlying flap.

Definition for the term "site" precedes code D2410.

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, for dental consultant review.

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).

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