Periodontics Section - Combined Connective Tissue and Double Pedicle 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

Combined connective tissue and double pedicle graft (D4276):
Advanced gingival recession often cannot be corrected with a single procedure. Combined tissue grafting procedures are needed to achieve the desired outcome.

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

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).
4. Isolated deep recession in the presence of a mucogingival defect.

Administrative Guidelines
Process to contract benefits.

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