CareFirst Clinical Policy Updates

American Dental Explanation Note Association Nomenclature • Do not use to report bone grafts placed in conjunction with implants or D4263 implant . D4264 • These are periodontal codes.

These codes may be used • GTR inhibits epithelial cell migration into wound. when performing GTR for D4266 – D4267 • If the implant is contra-indicated or the plan excludes implant coverage, both implant and the graft may not be covered. periodontal reasons

• Not appropriate at time of implant surgery. • No benefit will be allowed when reported with D6010. Bone graft for ridge D7953 • Routine grafting of extraction sites is not covered. preservation • If the implant is contra-indicated or the plan excludes implant coverage, the graft may not be covered.

• has become a common procedure related to implant surgery. • No benefit is allowed for sinus lift, there is no implant benefit or implant is denied as not medically necessary. D7951: Lateral approach Sinus lift • Sinus lift with coincidental implant placement in the same site is not D7952: Vertical approach recommended unless vertical bone height of 4mm or greater is adequate to stabilize the implant and greatly improves the prognosis. • If the implant is contra-indicated, the lift and implant will be denied.

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American Dental Explanation Note Association Nomenclature

Indicated in the following cases: • Advanced or chronic implantitis that does not respond to antibiotic therapy. • Lack of . Requires report or letter of • Broken or fractured fixture. D6100: Implant removal, by report medical necessity, recent • Internal thread stripping necessitating replacement. radiographic image • Significant bone defect. • Involved in tumor or cyst – large area of radiolucency or radiopacity involving the implant. • See above D6100 statement for more information.

And surface cleaning of • Indicated for removal of biofilm, plaque and from implant D6101: of peri-implant exposed implant surfaces surface within the defect. defect including flap entry and • No benefit when performed with D4260, D4261. closure; Single implant

• No benefit when performed with D4260, D4261. Includes surface cleaning of • Indicated for removal of biofilm, plaque and calculus from implant D6102: Debridement and osseous exposed implant surfaces, surface within the defect. contouring of a peri-implant defect includes flap entry and • Need to re-contour osseous defect proximal to implant to permit healing. closure; Single implant • Defect should be radiographically apparent.

Not including flap entry and closure or, when • Use to report grafts related to implant site repair. D6103: Bone graft for repair of peri- indicated, placement of • No benefit when performed with D4260, D4261. implant defect or • Incidental when reported with D4263, D4264 in same site. biologic materials to aid in • D4265, 4266/4267 reported separately. osseous integration

American Dental Explanation Note Association Nomenclature

• May be appropriate coincidentally with implant placement depending upon bone architecture, size of defect, size of implant. • May be appropriate when implant is placed immediately into extraction Note: D4263, D4264, site. D7953 should not be used • Contraindicated in untreated cases of periodontal infection, uncontrolled D6104: Bone graft at time of implant to report bone grafts diabetes, heavy smokers. placement performed in conjunction • Synthetic bone graft material is not recommended. with implants • If the implant is contra-indicated or not covered per contract, the benefit will be denied. • Typically, the implant is allowed to osseointegrate and graft mature before loading.

• May be appropriate and is dependent upon quality and bone mass in Immediate loading addition to loading forces. • Any movement of the implant will inhibit osseointegration.

• Inhibits healing: may interfere with osseointegration and soft tissue Smoking repair.

• Special care may be required to avoid inflammatory response. • Generally, most conditions will not negatively affect outcomes. Metabolic disorders • Good is a critical factor. • Bone quality is of utmost importance.