Number: 013
Update

Subject: Bone Replacement Grafts for Periodontal Surgical Procedures

Date: May 21, 2018

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, which are excluded and which are subject to dollar caps or other limits. Members and their dentists will need to refer to 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. Coverage may be available for DIN oral surgery procedures under either medical or dental plans.

Background

Bone replacement grafts for dentoalveolar bone defects may be necessary for various reasons. Bone defects are most often present in conjunction with pathology that is associated with the teeth in periodontal disease. Bone grafts are generally used in an attempt to restore normal architecture to the bone that supports the teeth, increasing stability of the affected tooth/teeth.

Periodontal loss of bone can occur in either a vertical or horizontal manner on either the mesial or distal aspects of the roots. With advanced cases of localized or generalized periodontitis, loss of bone may be demonstrated within the furcation of the molar teeth. The furcation is defined as the anatomic area of a multi-rooted tooth where the roots diverge.

Review of recent literature related to bone grafting of bone defects describes the success or failure of bone replacement grafts within various furcation defects. Class 2 furcation defects located on the buccal of maxillary and mandibular molars and on the lingual of mandibular molars often respond favorably to bone replacement procedures. However, palatal Class 2 furcation defects on maxillary molars and any Class 2 furcation defect on maxillary first bicuspid teeth usually respond less favorably to bone grafting procedures. Class 3 furcation involvement (through and through from buccal to lingual and mesial to distal) do not respond well to bone replacement grafts and have fair to poor long-term prognosis.¹

Medical necessity for osseous grafts is based on radiographic evidence of vertical (intrabony) osseous defects and/or the millimeter pattern of periodontal pocket measurements provided on a six-point-per-tooth chart. In areas where there is radiographic evidence of horizontal bone loss and minimal pocket depth determinations, a graft placement may not be considered medically necessary.

Codes²

D4263 - Bone replacement graft - retained natural tooth -  first site in quadrant
D4264 - Bone replacement graft - retained natural tooth -  each additional site in quadrant

See Dental Clinical Policy Bulletin 001 -
Use of Bone Grafts in Conjunction with Apicoectomies, Extractions and/or Implants

Revision Dates

Original policy: November 22, 2005
Updated: February 22, 2010; August 8, 2011; September 10, 2012; November 5, 2013; December 8, 2014; November 23, 2015; November 22, 2016; May 21, 2018
Revised: November 1, 2006; February 4, 2008; February 24, 2009

The above policy is based on the following references:

¹1996 World Workshop in Periodontics-Annals of Periodontology Vol. 1, Number 1, November 1996. Section 7. Periodontal regeneration around natural teeth, 621-666.

²Americal Dental Association. CDT 2018 Dental Procedure Codes.*

⁴American Academy of Periodontology. Position Paper: Periodontal regeneration, J Periodontol 2005;76:1601-1622.

⁵Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL, Gunsolley JC. The efficacy of bone replacement grafts in the treatment of periodontal osseous defects; a systematic review. Ann Periodontol 2003;8:227-265.

*Copyright 2017 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.