D4270—Pedicle soft tissue graft
Purpose: A pedicle tissue graft is performed to "fix" gum recession. This procedure code can be used to report the tunneling procedure technique or the Chao Pinhole Surgical Technique. It involves augmenting the gingiva to obtain adequate root coverage.
There are many variables involved when it comes to dental insurance coverage and reimbursement for this procedure.
• Dental insurance companies usually cover only if the correct information is reported.
• Submitting the claim with x-rays and periodontal charting is not enough to facilitate coverage and payment.
• A clear written narrative that explains the need for the procedure must be submitted.
• Gingival recession must be noted in the narrative at 5 mm or greater in order for insurance companies to approve coverage.
• Gingival inflammation should be noted in the narrative: mild, moderate, or severe.
• The amount of keratinized/non-keratinized gingiva must be noted in the narrative in order for insurance companies to approve coverage.
• The amount of attached and unattached gingiva must be noted in order for insurance companies to approve coverage.
• Root sensitivity must be noted in the narrative at moderate sensitivity in order for insurance companies to approve coverage.
• If root caries exists, it must be noted in the narrative.
• Mobility must be noted. If mobility exists, the procedure may be denied.
• A 24- to 36-month exclusion applies. This means the same insurance will cover only the procedure in the same teeth reported every 24 to 36 months.