Subject: Soft Tissue Graft Procedures
Reviewed: March 13, 2014
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:
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.
Aetna considers these surgical procedures to be dental-in-nature (DIN) oral surgery. Coverage may be available for DIN oral surgery procedures under either medical or dental plans.
Soft tissue grafts, including pedicle grafts, free gingival grafts, subepithelial connective tissue grafts and combination procedures, are surgical procedures designed to increase the zone of keratinized tissue around the tooth root or implant, deepen the vestibule or eliminate prominent frenum involvements. These procedures are performed to stop progressive recession and/or to provide gingival coverage over sensitive root surfaces.
Soft tissue defects include, but are not limited to, dehiscences, fenestrations and inadequate gingival margins. Defects can occur in areas with minimal pocket depth and are generally localized to either the facial or lingual tooth surfaces. Typically, there is very little or no interproximal bone loss associated with these defects, and the defects are usually restricted to the same vestibular surfaces.
Basic pocket depth measurements and radiographs cannot adequately demonstrate facial or lingual soft tissue loss and have minimal diagnostic value in documenting this pathosis. A chart or narrative containing mucogingival data including millimeters of recession and millimeters of attached gingiva and/or keratinized tissue is required for each tooth/site proposed to receive a soft tissue graft.
D4270 -- Pedicle soft tissue graft procedure
D4271 -- Free soft tissue graft procedure (including donor site surgery)
D4273 -- Subepithelial connective tissue graft procedures, per tooth
D4275 -- Soft tissue allograft
D4276 -- Combined connective tissue and double pedicle graft, per tooth
D4277 -- Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in a graft
D4278 -- Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in graft
Original policy: April 12, 2005
Updated: September 5, 2007; February 28, 2011; July 12, 2012; January 14, 2013; March 13, 2014
Revised: March 15, 2006; December 29, 2008; December 21, 2009
The above policy is based on the following references:
1 American Dental Association. Current Dental Terminology, CDT-2014: 35-36.*
2 Annals of Periodontology. 1996 World Workshop in Periodontics. 1996; 1(1).
3 American Academy of Periodontology. Insurance policy statement: soft tissue grafting. November 2002.
*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.