Guided Tissue Regeneration (GTR) (002)

Number: 002
(Updated)

Subject: Guided Tissue Regeneration (GTR)

Reviewed: June 9, 2014

Important note

This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made these decisions based on a review of currently available clinical information including:

• Clinical outcome studies in the peer-reviewed published medical and dental 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 and dentists practicing in relevant clinical areas
• Other relevant factors

We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to consult the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply. The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider 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.

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
Revised: December 5, 2005

The above policy is based on the following references:

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

2 American Dental Association. CDT 2014 Dental Procedure Codes: 34.*
 
3 Needleman 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 23, 2014. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16625546

*Copyright 2013 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.