Does Medi-Cal Cover Bone Graft? Exceptions, Codes, and Costs

Medi-Cal does not cover bone grafts as a standalone dental benefit. The program’s dental fee schedule lists the main bone graft procedure codes as “Not a Benefit,” which means patients needing a graft for gum disease, socket preservation, or implant preparation generally pay out of pocket. Two narrow pathways exist: a graft placed during approved root-end surgery, and bone reconstruction tied to trauma, cancer, or congenital jaw conditions. Both require prior authorization and documentation of medical necessity.

Which Bone Graft Codes Medi-Cal Excludes

The Medi-Cal Dental Schedule of Maximum Allowances marks the following codes as “Not a Benefit,” meaning the program will not pay for them under the standard fee schedule:

D4263: bone replacement graft for a retained natural tooth, first site in a quadrant.
D4264: bone replacement graft for a retained natural tooth, each additional site in a 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 at the same surgical site.

D4263 and D4264 are the codes used for the periodontal bone grafting most patients ask about, including grafts to treat gum disease or preserve bone around existing teeth. Their exclusion means Medi-Cal does not pay for periodontal bone grafts under the standard fee schedule. Related regeneration procedures, including D3431 (biologic materials to aid tissue regeneration with periradicular surgery) and D3432 (guided tissue regeneration with a resorbable barrier), are also classified as not a benefit.¹

The Exception for Grafts With Root-End Surgery

Although the fee schedule lists D3428 and D3429 as not a benefit, the Medi-Cal Dental Utilization Review Criteria Guidelines published by Comagine Health describe the same codes as covered when performed alongside approved periradicular (root-end) surgery.² A bone graft placed during an approved apicoectomy or similar procedure can be authorized; the graft on its own, without the qualifying surgery, cannot.

Approval requires several things:

The associated periradicular surgery (D3471, D3472, or D3473) must first be approved for the tooth in question.
The provider must submit arch and periapical radiographs showing why the graft is medically necessary.
If the radiographs alone do not establish necessity, the provider must submit a written narrative identifying the specific root being treated.
Both D3428 and D3429 require a Treatment Authorization Request (TAR) before the procedure.

D3429 cannot be approved for an additional tooth unless D3428 has already been approved for the primary tooth at the same site.² The graft material in these cases is non-autogenous, meaning donor or synthetic rather than the patient’s own bone.

Grafts Tied to Dental Implants

Medi-Cal covers dental implants only when “exceptional medical conditions are documented,” per the state’s benefits guide.³ In practice this has been interpreted to mean patients who cannot wear dentures for anatomical reasons.⁴ A dentist must submit a TAR to the Department of Health Care Services for review.

Whether a bone graft used to prepare the jaw for an approved implant can be covered is not clearly spelled out in the available Medi-Cal documentation. The standalone bone graft codes remain excluded, but certain implant surgical procedures (D6010, D6013, D6040, D6050) are paid “By Report,” meaning case-by-case review rather than a fixed rate.¹ If an implant is approved under the exceptional-conditions pathway, ask the provider to include any necessary bone grafting in the same TAR.

Reconstructive Grafts for Trauma, Cancer, or Congenital Conditions

Bone grafts performed as oral and maxillofacial surgery for trauma, cancer reconstruction, or congenital conditions like cleft palate fall into a separate category. Medi-Cal covers maxillofacial services, and they are exempt from the program’s annual benefit cap for adults.⁵ Under California Health and Safety Code Sections 1367.63 and 1367.68, health plans cannot exclude surgical procedures for conditions directly affecting the jawbone if doing so would amount to a failure to provide medically necessary care.⁶

Reconstructive surgery under these statutes covers procedures to correct abnormal jaw structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Ridge reconstruction and jaw reconstruction are specifically referenced as covered when medically necessary, such as after tumor removal or cancer surgery. Cleft palate-related dental services that are an integral part of reconstructive surgery are also covered.⁶ Prior authorization is required and the procedure must meet accepted standards of care.

What a Bone Graft Costs Out of Pocket

For patients paying themselves, prices in California vary with the graft material, the complexity of the procedure, and the provider. Reported ranges include:

Synthetic or donor bone graft: $200 to $1,200 per site.
Autograft, using the patient’s own bone: $2,000 to $3,000, reflecting the additional surgery to harvest bone.
Combined bone graft and implant: $3,000 to $6,000 per site, depending on whether additional procedures like sinus lifts or ridge augmentation are needed.

Imaging adds to the total: X-rays run roughly $60 to $250 and CT scans $250 to $1,000.⁷ Dental schools, including UCLA School of Dentistry and USC’s Herman Ostrow School of Dentistry, offer reduced-cost procedures performed by supervised students. Many private practices also accept payment plans or third-party financing.⁸

If Your Treatment Authorization Request Is Denied

When a TAR for a bone graft is denied, start by asking the dental provider to submit a re-evaluation or a new TAR with additional documentation of medical necessity.⁵

If that does not resolve the issue, you can file a complaint with Medi-Cal Dental at (800) 322-6384 or by written complaint form. You also have the right to request a State Hearing through the California Department of Social Services. The request must be made within 90 days of the Notice of Action explaining the denial, and can be submitted through the Appeals Case Management System online, by phone at (800) 952-5253, by fax, or by mail.⁵

Patients enrolled in a Medi-Cal managed care dental plan follow a slightly different path. Health Net, for example, directs members to Member Services first and offers expedited review when a delay poses a serious threat to health. If the plan’s internal grievance process does not resolve the matter within 30 days, members can escalate to the California Department of Managed Health Care, which can arrange an Independent Medical Review for disputes about medical necessity.⁹

1
California DHCS. Medi-Cal Dental Schedule of Maximum Allowances
2
Comagine Health. Dental Utilization Review Criteria Guidelines
3
News Medical. Medi-Cal’s Dental Care Gap: Getting a Tooth Pulled Is Easy, Much Harder to Get an Implant
4
Mountainside Dental. Does Medi-Cal Cover Dental for Adults
5
Disability Rights California. Dental Services Through Medi-Cal
6
UnitedHealthcare. Dental Care and Oral Surgery Policy
7
Southland Dental Care. Bone Graft Cost for Dental Implant in Los Angeles
8
Zocdoc. Los Angeles Bone Graft Dental Cost
9
Health Net. Medi-Cal Dental Appeals and Grievances