Immediate surgical placement of implant body with soft tissue grafting, osseous grafting and guided tissue regeneration (009)

Number: 009
(Updated)

Subject: Immediate surgical placement of implant body with soft tissue grafting, osseous grafting and guided tissue regeneration

Reviewed: October 28, 2021

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

Immediate placement of dental implant bodies in tooth extraction sites is an acceptable procedure that may or may not require osseous grafting procedures. These procedures may include the use of autogenous bone or various types of freeze-dried or decalcified freeze-dried bone graft materials from tissue banks or commercially processed bovine porous bone mineral. Immediate placement, with or without osseous grafting, is usually, and appropriately, supplemented with the placement of a guided tissue regenerative membrane or connective tissue membranes.

The FDA has not approved biologic mediators (enamel matrix derivatives [EMD]) for use with immediate placement of implants. Therefore, Aetna does not consider them appropriate to use in this clinical situation.

Periodontal pathosis related to the immediate implant site will be addressed as part of the implant placement process. However, all other active periodontal disease in the patient's oral cavity must have been treated and under control before immediate placement of implants in an extraction site will be considered for benefit determination.

Background

Dental literature and clinical studies² continue to support successful new bone regeneration around implants when non-synthetic osseous grafting materials and guided tissue regeneration (GTR) procedures are applied at the time of implant body placement. Additionally, new reports support the use of bovine porous bone mineral as an acceptable heterogeneous grafting material.

The most favorable clinical environment for immediate implant placement is after the atraumatic removal of teeth because of failed endodontic therapy or coronal and/or root fracture. When the implant body can be closely adapted to the remaining osseous walls of an extraction site, studies indicate that osseous grafting may not be necessary to ensure the formation of new bone. The associated blood clot formation alone will usually bridge the narrow space between the osseous walls and the implant body, acting as a matrix for bone regeneration without the addition of bone graft material.

When implants cannot be closely adapted to remaining osseous walls because of bone loss, autogenous and/or allogenic osseous grafts are necessary to provide a scaffold for regenerative cells originating from contiguous tissues. These regenerative cells and the scaffolding are essential to the proper osseointegration of the implant.

Osseointegration has been described as a direct structural and functional connection between living bone and the surface of a load-carrying implant. Proliferation of vasculature (blood vessels) originating from the osseous walls must cross the scaffolding and inhabit the space between the bone and implant before proliferating vasculature from the gingival epithelium reaches this area. If vasculature originating from the gingival epithelium reaches the osseous-implant "gap" first, soft tissue interference with the osseointegration process will occur.

While most synthetic graft materials continue to be useful as biologic fillers, they produce little, if any, periodontal and bone regeneration. At this time, with the exception of bovine porous bone mineral, synthetic graft materials do not appear to be efficacious for grafting procedures associated with the immediate placement of implants.

Immediate placement of implants directly into extraction sites usually and appropriately requires the placement of a guided tissue regenerative (GTR) membrane to delay the proliferation of wound-healing vasculature originating from gingival epithelial tissues. Barrier placement is essential for optimal wound healing and osseointegration, even when bone grafts are not used. However, benefits for bone grafts and guided tissue regenerative (GTR) will vary depending on the member’s plan design, and these services may be excluded from coverage.

Codes¹

D4265 – biologic materials to aid in soft and osseous tissue regeneration
D4266 – guided tissue regeneration - resorbable barrier, per site
D4267 – guided tissue regeneration - nonresorbable barrier, per site
D4270 – pedicle soft tissue graft procedure
D4273 – subepithelial connective tissue graft procedure
D4275 – soft tissue allograft
D4276 – combined connective tissue and double pedicle graft, per tooth
D4277 – free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft
D4278 – free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site
D4283 – autogenous connective tissue graft procedure (including donor and recipient surgical sites) - each additional contiguous tooth, implant or edentulous tooth position in same graft site   
D4285 – non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) - each additional contiguous tooth, implant or edentulous tooth position in same graft site
D6010 – surgical placement of implant body - endosteal implant
D6104 – bone graft at time of implant placement
D6013 – surgical placement of mini implants

Revision dates

Original Policy: February 3, 1994
Updated: December 21, 2009; February 28, 2011; July 12, 2012; August 12,2013; June 9, 2014; March 7, 2016; March 15, 2017; April 26, 2018; April 29, 2019; May 6, 2020; October 28, 2021
Revision Dates: August 16, 2000; April 12, 2005; March 15, 2006; September 21, 2007; December 29, 2008

The above policy is based on the following references:

¹American Dental Association. CDT 2021 Dental Procedure Codes.*

²Hämmerle C.H.F., Tarnow D. The etiology of hard- and soft-tissue deficiencies at dental implants: a narrative review. J Periodontol. 2018; 89: S291-S303

*Copyright 2021 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.