CurrentAnthemPolicy 07-101

Removal of Teeth

Governs clinical review criteria and documentation requirements for removal (extraction) of erupted or impacted teeth for Anthem dental plans; affects providers submitting claims for tooth extractions and utilization review teams.

Policy Summary

PayerAnthem

PolicyRemoval of Teeth

Policy CodePolicy 07-101

Change TypeNo material change

Effective DateJan 1, 2022

Next Review Date

Key ActionProvide diagnostic periapical or panoramic images for all extractions and submit operative report or intraoral photos when surgical elements are billed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12+procedure codes referenced

Imaging requiredimaging requirement

D7251coronectomy included

Symptomatic/pathologiccoverage stance summary

Coverage Criteria for Removal of Teeth

Initial Coverage Criteria

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Primary clinical indications: Extraction is indicated for conditions such as pain, dental caries, periodontal disease, periapical pathology, split/cracked tooth, tooth mobility, internal or external root resorption, infection, severe anomaly of the crown or root precluding restorative/prosthetic treatment, traumatic injury, loss of pulp vitality typically secondary to infection, ectopic position causing damage to other teeth, teeth in the line of fracture, or prophylactic removal related to organ transplant, chemotherapy, radiation therapy, prosthetic heart valve or joint replacement, or for orthodontic purposes.

See clinical indications and policy guidance.

Exclusion for convenience or cosmetic reasons: Removal is not benefited and will be denied if the tooth does not present with one of the indicated clinical reasons, is for patient or dentist convenience, or is for cosmetic purposes.

Policy denial trigger.

Imaging requirement: Appropriate diagnostic periapical or panoramic images must be provided for all extractions.

Imaging required to support any extraction claim.

Classification of impaction and documentation: Impacted teeth must be classified as soft tissue, partial bone, or complete bone impactions; an impacted tooth is not considered pathologic unless associated pathology is documented. When surgical or impaction status is not evident from submitted documentation, provide a complete operative report and/or intraoral photos.

See definitions of impaction and documentation requirements.

Surgical extraction criteria: For an extraction to be considered surgical (and billed with surgical codes), documentation must demonstrate soft tissue incision, flap reflection, removal of soft and/or osseous tissue, complete removal of the tooth and roots, and closure of the surgical site; if surgical elements are not evident, submit a complete operative report and/or intraoral photos.

Surgical extraction definition and required supporting documentation.

Special considerations for complex removals: Special anatomic or technical factors that may support surgical coding include intimate involvement of roots with the mandibular canal or adjacent roots, obstruction by the mandibular ramus, unusually low tooth position, unfavorable access/angulation, proximity to the maxillary sinus, or root dilacerations/abnormality; these must be supported by clinical notes and/or narrative.

Examples of special considerations that justify surgical approach.

Third molar (wisdom tooth) considerations: Erupted third molars do not automatically qualify as surgical extractions; most are elective unless documented root abnormality or inability to obtain purchase necessitates surgical access. Some plans require impacted third molars to be symptomatic or pathologic to qualify; when one third molar is symptomatic/pathologic, removal of the opposing asymptomatic third molar may be permitted depending on contract benefits.

Third molar policy and opposing-tooth consideration.

Procedure Codes

Covered CDT Codes (informational list)CDT

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 bony, with unusual surgical complications.
D7250	Surgical removal of residual tooth roots (cutting procedure).
D7251	Coronectomy - intentional partial tooth removal.

Provider Documentation and Billing Requirements

Documentation Required

Documentation to support billed CDT codes

Documentation to support billed CDT codes: Appropriate diagnostic periapical or panoramic images must be provided for all extractions. When surgical elements are billed (e.g., soft tissue incision, flap reflection, removal of soft and/or osseous tissue, complete removal of the tooth and roots, and closure of the surgical site), the submitted clinical information must demonstrate those surgical elements. If surgical extraction is not evident from the documentation, provide a complete operative report and, when applicable, intraoral photos or other imaging (panoramic, periapical, cone beam CT) to substantiate the procedural code submitted. For soft tissue, partial bone, or complete bone impaction extractions, include clinical notes describing the impaction type and any flap elevation or bone removal. For residual root removals, documentation must show roots partially encased in bone; root tips lacking bony support should be reported as D7140.

Required imaging: diagnostic periapical or panoramic images for all extractions
When surgical elements are billed: include complete operative report and intraoral photos as appropriate
For procedures involving bone or proximity concerns: include narrative describing complications (e.g., mandibular canal involvement, proximity to maxillary sinus)
Coronectomy: document risk to inferior alveolar nerve (panoramic +/- cone beam CT) when applicable

Denial Risk

Denial triggers

Denial triggers: Removal of teeth is not benefited if the teeth do not present with an indicated clinical reason (symptomatic or pathologic as defined by the member's contract), are removed for patient or dentist convenience, or for cosmetic reasons. Erupted third molars do not automatically qualify as surgical extractions; without documented clinical evidence (e.g., root dilaceration, lack of purchase point, need for soft tissue incision/flap and bone removal) surgical procedure billing will be considered elective and may be denied. When any service is performed in conjunction with or in preparation for a non-covered or denied service, all related services may also be not covered or denied.

Denial if no documented clinical indication (symptomatic or pathologic) or if for convenience/cosmetic reasons
Denial risk when surgical extraction billed but documentation does not show required surgical elements (operative report, imaging, photos)
Erupted third molars billed as surgical without supporting evidence may be considered elective and denied
Related services may be denied if tied to a non-covered or denied service

Note

Opposing tooth removal consideration

Opposing tooth removal consideration: Depending on plan design, when a single third molar is symptomatic or pathologic, benefits might be available to remove the opposing, asymptomatic, non-pathologic third molar on the same date of service. Verify contract benefits and document clinical rationale and same-date operative plan when removing an opposing tooth.

Benefits for removal of opposing asymptomatic third molar may be plan-dependent
Document symptomatic/pathologic status of the index tooth and rationale for same-date removal of opposing tooth

Background and Indications

Indications for extraction include conditions that make the tooth non-restorable or pose clinical risk: pain, dental caries that cannot be restored, periodontal disease with significant attachment loss or mobility, periapical pathology, a split or cracked tooth, tooth mobility, internal or external root resorption, infection, severe crown or root anomalies that preclude restorative treatment, traumatic injury, loss of pulp vitality secondary to infection, ectopic position causing damage, teeth located in fracture lines, and prophylactic removal related to immunosuppression or orthodontic treatment. Impacted teeth are not considered pathologic solely by their position; they are covered only when associated with documented pathology or symptoms.

Definitions

Impacted tooth — definition and clinical note

DefinitionA tooth that cannot fully erupt into function because of abnormal position or impingement by other anatomic structures which block the normal eruption pathway; an impacted tooth is not considered pathologic unless associated pathology is documented.

Clinical note — classificationImpactions are classified by tissue/bony coverage: soft tissue impaction (crown partially/completely covered by soft tissue), partial bone impaction (crown not fully covered by bone; requires flap elevation and bone removal), and complete bone impaction (crown mostly or fully covered by bone).

Documentation requirementAppropriate diagnostic periapical or panoramic images must be provided for all extractions; when the type of impaction is not evident, provide a complete operative report and/or intraoral photos.

Surgical extraction — definition

DefinitionA surgical extraction is a procedure that requires soft tissue incision, flap reflection, removal of soft and/or osseous (bone) tissue, complete removal of the tooth and roots, and closure of the surgical site.

When surgical designation appliesApplies to soft tissue, partial bone, or complete bone impactions and to erupted teeth when root formation or position dictates surgical removal (e.g., need for bone removal or sectioning of the tooth).

Documentation to support codeWhen surgical extraction is billed, submitted clinical information must demonstrate incision, flap reflection, bone removal as applicable, complete tooth/root removal and closure; if not evident, provide a complete operative report and/or intraoral photos.

Coronectomy — definition and indications

DefinitionCoronectomy (reported as D7251) is intentional partial tooth removal in which the crown is removed while retaining the roots to reduce risk to the inferior alveolar nerve, typically performed for lower third molars when nerve injury risk is moderate to high.

When indicatedConsider coronectomy for lower third molars with intimate root relationship to the mandibular canal or other anatomical factors posing elevated risk for nerve injury; special considerations should be supported by clinical notes and/or narrative.

Coding noteCoronectomy is specifically reported with CDT code D7251 as an intentional partial tooth removal procedure.