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 surgery. 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. • Sinus lift 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. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association. BlueImpressionsVol13Issue2_ClinicalPolicyUpdates (6/16) ®’ Registered trademark of CareFirst of Maryland, Inc. American Dental Explanation Note Association Nomenclature Indicated in the following cases: • Advanced or chronic implantitis that does not respond to antibiotic therapy. • Lack of osseointegration. 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 calculus from implant D6101: Debridement 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 barrier membrane 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 oral hygiene is a critical factor. • Bone quality is of utmost importance. .