D4285 - Addl Non-Autog Gft
Non-autogenous connective tissue graft - addl tooth.
- Procedure Code
- D4285
- Category
- Periodontics
Insurance Verification Benchmarks & Billing Guidelines
Benchmark Policy Source: Delta Dental 2026
- Frequency Limitation
- Subject to group/individual contract frequency limitations (none)
Required Claim Attachments & Pre-Submission Checklist
- Full-mouth periodontal charting with 6-point probing depths and bleeding points
Bill When (Allowable Clinical Criteria)
- Benefits are limited to up to two or teeth soft tissue grafts per quadrant.
Restrictions & Clinical Exclusions
- Periodontal surgical procedures include all necessary postoperative care, finishing procedures, oral evaluations for three months. Soft tissue grafts may be allowed on the same teeth/sites within 36 months with supporting documentation. When a surgical procedure is billed within three months of the initial surgical procedure in relation to both natural teeth and implants by the same dentist/dental office, the fee for the surgery is not billable to the patient. In the absence of documentation of extraordinary circumstances, the fee for additional surgery by the same dentist/dental office for three years is not billable to the patient. If extraordinary circumstances are present, the benefits will be denied and is chargeable to the patient up to the approved amount for the surgery. not billable to the patient
- Periodontally involved teeth which would qualify for surgical pocket reduction benefits under these procedure codes must be documented to have at least 5 mm pocket depths and bone loss beyond 1-1.5 millimeters. If pocket depths are under 5 mm, then benefits are denied.
- If surgery is performed less than four weeks after scaling and root planing, fees for the surgical procedure or the scaling and root planning by the same dentist/dental office are not billable to the patient following consultant review.
- Periodontal surgical procedures include all necessary postoperative care, finishing procedures, oral evaluations for three months, as well as any surgical re-entry for three years. When a surgical procedure is billed within three months of the initial surgical procedure by the same dentist/dental office, the fee for the surgery is not billable to the patient. In the absence of documentation of extraordinary circumstances, fees for additional surgery are not billable to the patient for three years.
- Benefits for GTR and or bone grafts, in conjunction with soft tissue grafts in the same surgical area, are denied.
- Fees for a frenectomy (D7961 and D7962) or frenuloplasty (D7963) are not billable to the patient when performed in conjunction with soft tissue grafts contiguous tooth position in same graft site.
Common Claim Denial Codes & Overturn Strategies
| Denial Code | Denial Reason | Appeal & Overturn Strategy |
|---|---|---|
| CO-119 | Benefit maximum or frequency limitation exceeded for procedure | Submit clinical narrative detailing extraordinary circumstances, active recurrent pathology, or exception criteria. |
ICD-10 Justification & Crosswalk Mappings
| ICD-10 Code | Diagnosis Name | Category | Primary Justification | Claim Type | Clinical Scenario |
|---|---|---|---|---|---|
| K06.012 | Localized gingival recession, moderate | Other disorders of gingiva and edentulous alveolar ridge | Yes (Primary) | BOTH | 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 indicated for Localized gingival recession, moderate |
| K06.010 | Localized gingival recession, unspecified | Other disorders of gingiva and edentulous alveolar ridge | Secondary | BOTH | 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 indicated for Localized gingival recession, unspecified |
| K06.011 | Localized gingival recession, minimal | Other disorders of gingiva and edentulous alveolar ridge | Secondary | BOTH | 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 indicated for Localized gingival recession, minimal |
| K06.013 | Localized gingival recession, severe | Other disorders of gingiva and edentulous alveolar ridge | Secondary | BOTH | 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 indicated for Localized gingival recession, severe |
| K06.020 | Generalized gingival recession, unspecified | Other disorders of gingiva and edentulous alveolar ridge | Secondary | BOTH | 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 indicated for Generalized gingival recession, unspecified |
| K06.021 | Generalized gingival recession, minimal | Other disorders of gingiva and edentulous alveolar ridge | Secondary | BOTH | 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 indicated for Generalized gingival recession, minimal |
| K06.022 | Generalized gingival recession, moderate | Other disorders of gingiva and edentulous alveolar ridge | Secondary | BOTH | 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 indicated for Generalized gingival recession, moderate |
| K06.023 | Generalized gingival recession, severe | Other disorders of gingiva and edentulous alveolar ridge | Secondary | BOTH | 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 indicated for Generalized gingival recession, severe |