Bone grafting is one of the most valuable adjuncts for preserving bone and preparing for prosthetics. It is the only solution to reverse dental bone loss and is a well-accepted procedure required in 1 in every 4 dental implants.
It’s also one of the most frequently denied procedures by insurance carriers. If you’ve ever seen “not covered,” “wrong code,” or “resubmit with appropriate code” stamped on your graft claim, you’re not alone.
The issue isn’t the clinical necessity -- most grafts are fully justified. The issue is coding. With the recent Code on Dental Procedures and Nomenclature (CDT) revisions in implant services, grafts are being reviewed more closely. The same automated systems that flag implant code mismatches are now kicking out graft claims when the CDT, the International Classification of Diseases, 10th Revision (ICD-10), and documentation don’t align.
Why auto-denials happen
The majority of graft denials happen automatically. They’re triggered before a human reviewer even looks at the claim. The system checks for any code mismatches or missing elements and spits back a denial.
The most common pain points include:
- The wrong context: D7953 (ridge preservation) used with an implant procedure. Systems expect D6104.
- The wrong site: D4263/D4264 (bone graft around a natural tooth) reported on an edentulous or implant site. Instant rejection.
- No ICD-10 match: Submitting a graft code without associating it with periodontitis, ridge atrophy, or bony defects. Without that info, the system sees no need if the insurer is configured to recognize diagnosis codes.
- Outdated definitions: CDT code descriptors change. With the implant update that rolled into 2025, payers are using new definitions to justify denials. If your coding follows last year’s rules, you’re already out of compliance.
Types of bone grafts and indications
Understanding the specific indications for each type of bone graft is crucial for accurate coding and claim submission.
Bone replacement grafts for retained natural teeth -- teeth in mouth
Indications: Infrabony/intrabony defects, class II furcation involvements.
Applicable CDT codes:
- D3428 -- Bone graft in conjunction with periradicular surgery - per tooth - single site
- D3429 -- Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site
- D4263 -- Bone replacement graft - retained natural tooth - first site in quadrant
- D4264 -- Bone replacement graft - retained natural tooth - each additional site in quadrant
- D3428 -- Bone graft in conjunction with periradicular surgery - per tooth - single site
- D3429 -- Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site
- D4263 -- Bone replacement graft - retained natural tooth - first site in quadrant
- D4264 -- Bone replacement graft - retained natural tooth - each additional site in quadrant
Bone replacement graft for ridge preservation -- edentulous
Indications: Following an extraction, when a planned dental prosthesis would be adversely affected by loss of ridge volume (affecting fit and/or function) or to prepare a site for implant placement.
Applicable CDT code: D7953 -- Bone replacement graft for ridge preservation - per site.
Implant bone grafts -- Implant in mouth
Indications: To restore or preserve bone volume for implant stability and osseointegration or to regenerate bone lost around an existing implant.
Applicable CDT codes:
D6103 -- Bone graft for repair of peri-implant defect (excluding flap entry and closure)
D6104 -- Bone graft at time of implant placement
Osseous, osteoperiosteal, or cartilage grafting -- edentulous
Indications: To augment deficient alveolar bone needed to support a dental prosthesis or placement of implants. This type of graft is used when the ridge is too thin and needs to be expanded to support an implant, bridge, or denture.
Applicable CDT code: D7950 -- Osseous, osteopriosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report.
Documentation is your best defense
When a graft claim is denied, we can’t just hit Resubmit. Documentation is required that tells the payer exactly why the graft was necessary and how it aligns with the code. This same documentation is vital if there is ever a dental board investigation or a malpractice claim.
Your SOAP (subjective, objective, assessment, and plan) note is key for payer communication. Here's a breakdown:
- Subjective: Patient's complaint/goals (e.g., "Patient seeks implant removal after implant failed to integrate on tooth #30 location.").
- Objective: Clinical findings like x-rays, 3D imaging, ridge dimensions, perio charting, and adjunctive testing.
- Assessment: Diagnosis with ICD-10 code (e.g., "Implant failed to integrate M27.61.").
- Plan: Treatment plan. Explain the bone graft's "why" (e.g., "ridge preservation for future implant placement"), defect morphology, and materials.
Beyond the SOAP note, attachments are paramount. They should always include these elements:
- Imaging: Attach x-rays, intraoral images, and 3D scans visually supporting the diagnosis and graft need.
- Product labels: Include labels/lot numbers for non-autogenous materials, detailing the composition and origin.
- A clear narrative: The clinical notes are the narrative! Include a concise explanation of the clinical decisions and graft necessity, tying all documentation together.
Failing to provide this detailed and thorough documentation gives the payer grounds to deny the claim, leading to unnecessary delays and financial complications.
Finally, appeals succeed when they look less like pleas and more like clinical defense files. Some practices see graft denials as part of the game and accept the loss.
Do not make this mistake. Bone grafts carry significant chair time, surgical skill, and material costs. Losing that reimbursement chips away at profitability and cash flow.
In today’s environment, where CDT updates roll out annually and insurers automate denials, falling behind on these crucial changes is the fastest way to shrink your margins.
Want the full coding and appeals guide?
This article provided an overview of correctly coding bone grafts. For the full "Bone Graft and Appeals Guide," email me at [email protected] with "Bone graft guide" in the subject line, and I’ll send it over.
Editor's note: References are available upon request.
Estela Vargas, CRDH, is the founder and CEO of Remote Sourcing, a dental insurance billing and revenue recovery service. She is a graduate of Miami Dade College's dental hygiene program. Vargas' extensive background in the clinical arena of dentistry is coupled with her experience as a practice administrator and business executive.
The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.
