CurrentAnthemPolicy 07-101

Removal of Teeth

Clinical guideline describing medical/dental necessity criteria for removal (extraction) of erupted and impacted teeth, definitions of surgical vs non-surgical extractions, special considerations (impactions, coronectomy), and related coding for dental plans. It governs review/coverage determinations when the plan performs utilization review for dental services.

Policy Summary

PayerAnthem

PolicyRemoval of Teeth

Policy CodePolicy 07-101

Change TypeAdministrative / clarified (no material clinical change)

Effective Date

Next Review Date

Key ActionProvide appropriate diagnostic periapical or panoramic images for all extraction claims; submit a complete operative report when surgical extraction is claimed but not evident from submitted clinical information.

SourceLink

POLICY UPDATE CHANGES

Policy revised (Status: Revised) with last review date 12/05/2020 and publish date 01/01/2021; document notes 'Updated' items without specific clinical changes.

9Key CDT procedure codes listed

12Numbered criteria/items in document

Coverage Summary

This guideline defines standards for determining medical/dental necessity for the removal (extraction) of erupted and impacted teeth in accordance with generally accepted standards of dental practice and applicable plan contract requirements, and emphasizes the need for documentation to support clinical and coding determinations. Coverage stance is mixed; whether a clinically necessary extraction is a covered benefit depends on the member's contract terms and plan design. Key thresholds include: Appropriate diagnostic periapical or panoramic images must be provided for all extractions and Coronectomy is offered when there is moderate to high risk of inferior alveolar nerve damage documented by panoramic exam (possibly supplemented by cone beam CT).

Key facts

Policy number07-101

SubjectRemoval of Teeth (tooth extractions)

StatusCURRENT

Last review date2020-12-05

Publish / effective date01/01/2021

Scope summaryClinical guideline describing medical/dental necessity criteria for removal (extraction) of erupted and impacted teeth, definitions of surgical vs non-surgical extractions, special considerations (impactions, coronectomy), and related coding for dental plans. Governs review/coverage determinations when the plan performs utilization review for dental services.

Medical-Necessity Criteria

Indications for Removal (Extraction) of Teeth

Removal of teeth is considered when ONE or more of the following indications are present:

ANY of the following

Pain
Dental caries
Periodontal disease
Periapical pathology
Split tooth (cracked tooth)
Tooth mobility
Internal or external root resorption
Infection
Severe anomaly of the crown/root precluding prosthetic/restorative treatment
Traumatic injuries to teeth
Loss of pulp vitality typically secondary to infection
Ectopic position in the dental arch causing damage to other teeth
Teeth in the line of fracture
Prophylactic removal required due to organ transplant, chemotherapy, radiation therapy, prosthetic heart valve replacement, joint replacement, or for orthodontic purposes

Documentation requirement

Appropriate diagnostic periapical or panoramic images must be provided for all extractions
When surgical extraction is claimed, documentation supporting surgical nature (e.g., complete operative report, intraoral photos) is required if not evident from submitted clinical information

Surgical vs Non-surgical Extraction Criteria

Determination that an extraction is surgical requires ALL of the following when applicable:

ALL of the following

Procedure requires a soft tissue incision and reflection
Removal of soft and/or osseous (bone) tissue is performed
Complete removal of the tooth and roots is performed
Closure of the surgical site is performed
If surgical extraction is not evident from submitted clinical information, a complete operative report is required

Impaction definitions (one of)

Coronectomy (Intentional Partial Tooth Removal)

Indications and considerations for coronectomy

ALL of the following

Generally performed on lower third molars (occasionally lower second molars)
Offered when there is moderate to high risk of damage to the inferior alveolar nerve documented by panoramic exam, possibly supplemented by cone beam CT
More appropriate in older individuals for bone-impacted lower third molars

Coding

CDT codes (informational list of procedure codes applicable to this document)CPT

D7111	Extraction, coronal remnants deciduous tooth
D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
D7210	Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap, if indicated
D7220	Removal of impacted tooth, soft tissue
D7230	Removal of impacted tooth, partially bony
D7240	Removal of impacted tooth, completely bony
D7241	Removal of impacted tooth, completely with unusual surgical complications
D7250	Surgical removal of residual tooth roots (cutting procedure)
D7251	Coronectomy intentional partial tooth removal

ICD-10-CM Diagnoses for Dental Diseases and ConditionsICD-10

No codes listed

Provider Actions / Documentation & Billing

Documentation Required

Imaging required for all extractions

Provide appropriate diagnostic periapical or panoramic images for all extraction claims; imaging supports determination of impaction and surgical necessity. Appropriate diagnostic periapical or panoramic images must be provided for all extractions.

Appropriate diagnostic periapical or panoramic images must be provided for all extractions

Documentation Required

Operative report required for surgical extractions

When surgical extraction is claimed but not evident from submitted clinical information, submit a complete operative report to support the procedural code. When relevant, include intraoral photos with the operative report to document the surgical nature of the procedure.

Documentation Required

Support special considerations with clinical notes/narrative

Document unusual anatomic or access complications with clinical notes and/or narrative to justify surgical coding. Examples include intimate involvement of tooth roots with the mandibular canal, proximity to the maxillary sinus, and root-root involvement or intimate involvement with roots of an adjacent tooth.

Mandibular canal involvement
Sinus proximity
Root-root involvement

Billing Rule

Coding guidance for retained root tips

Root tips lacking bony support should be reported as D7140 rather than as a surgical root removal code.

D7140

Background

Background: The guideline establishes clinical indications and criteria used to determine when tooth removal is medically or dentally necessary, distinguishing surgical from non-surgical extractions and outlining special considerations (impactions, coronectomy, residual roots). It places strong emphasis on documentation (imaging, operative reports, intraoral photos, and clinical notes) to support procedural coding and surgical necessity, and reiterates that coverage is subject to the member's contract terms and plan requirements. Evidence/references: AAOMS JOMS 2012; Oral and Maxillofacial Surgery Clinics 2015; ADA CDT 2011-2012.

Definitions

Impacted toothA tooth that cannot fully erupt into function due to abnormal position or impingement of other anatomic structures blocking the eruption pathway; not pathologic unless associated with pathology.

Surgical extractionExtraction requiring soft tissue incision/reflection, removal of soft and/or osseous tissue, complete removal of tooth and roots, and closure of the surgical site.

Soft tissue impactionCrown not fully erupted and partially or completely covered by soft tissue; generally below occlusion.

Partial bone impactionCrown not fully covered by bone; requires flap elevation and removal of bone.

Complete bone impactionCrown mostly or fully covered by bone; requires elevation and removal of bone.

Policy Summary

PayerAnthem

PolicyRemoval of Teeth

Policy CodePolicy 07-101

Change TypeAdministrative / clarified (no material clinical change)

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Removal of Teeth

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions / Documentation & Billing

Background

Clinical Thresholds & Imaging Requirements

Revision History