Number: 002
(Updated)

Subject: Guided Tissue Regeneration (GTR)

Reviewed: June 26, 2017

Important note

This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).

 Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in this Bulletin. The discussion, analysis, conclusions and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna’s opinion and are made without any intent to defame.

Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.

Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.

The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (for example, will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members.

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Policy

We consider this surgical procedure to be dental-in-nature (DIN) oral surgery. DIN oral surgery procedures may be covered under either medical or dental plans.

Background

GTR is a surgical procedure that aims to regenerate the periodontal tissues when the periodontal disease is advanced and could overcome some of the limitations of conventional therapy. A membrane is placed over the root surfaces or defect area following surgical exposure and debridement. The mucoperiosteal flaps are then adapted over the membrane and sutured. The membrane is placed to exclude epithelium and gingival connective tissue from the healing wound. This procedure may require subsequent surgical procedures to correct the gingival contours. Guided tissue regeneration may also be carried out in conjunction with bone replacement grafts or to correct deformities resulting from inadequate faciolingual bone width in an edentulous area.

According to the American Academy of Periodontology (AAP) position paper (2005), Periodontal Regeneration, periodontal intraosseous defects, especially those characterized by three bony walls, respond favorably with substantial bone fill when treated with GTR techniques. Similar techniques applied to mandibular class II furcation defects have produced clinical improvements in terms of decreased probing depths and improved clinical attachment levels. Use of GTR in treating maxillary class II and mandibular class III defects has produced inconsistent results.¹

Codes²

D4266 -- Guided tissue regeneration -- resorbable barrier, per site
D4267 -- Guided tissue regeneration -- nonresorbable barrier, per site (includes membrane removal)

Revision dates

Original policy: September 13, 2004
Updated: September 4, 2007; December 29, 2008; December 21, 2009; February 28, 2011; July 12, 2012; August 13,2013; June 9, 2014; June 22, 2015; May 23, 2016; June 26, 2017
Revised: December 5, 2005

The above policy is based on the following references:

¹American Academy of Periodontology. AAP Position Paper; Periodontal regeneration, 2005: 1-22.

²American Dental Association. CDT 2017 Dental Procedure Codes.*
 
³Needleman IG, Giedrys-Leeper E, Tucker RJ, Worthington HV. Guided tissue regeneration for periodontal infra-bony defects (Cochrane Review). Cochrane Database Syst Rev. 2006 Apr 19;(2):CD001724. Accessed June 22, 2015. 

⁴Stavropoulos A, Sculean A. Current status of regenerative periodontal treatment. Current Oral Health Reports. March 2017.Volume 4.Issue 1;34–43

*Copyright 2016 American Dental Association. All rights reserved.

Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.