CurrentAnthemPolicy 07-101

Removal of Teeth

Clinical guideline governing when extractions (erupted or impacted) of teeth are considered medically/dentally necessary for Anthem members and what documentation/coding supports benefit determination.

Policy Summary

PayerAnthem

PolicyRemoval of Teeth

Policy CodePolicy 07-101

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review Date

Key ActionProvide appropriate diagnostic periapical or panoramic images and supporting clinical documentation to substantiate billed CDT procedure codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15criteria items

9CDT codes referenced

NCjurisdiction

Requiredimaging requirement

Coverage Criteria

Medical Necessity Criteria

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Indication: Extraction is performed for an accepted clinical indication such as pain, dental caries, periodontal disease, periapical pathology, split (cracked) tooth, tooth mobility, internal or external root resorption, infection, severe crown/root anomaly precluding restoration, 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 necessitated by medical or orthodontic reasons.

See clinical indications

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

Radiographic documentation required for all extractions

Surgical extraction criteria: Procedure meets the definition of surgical extraction (requires soft tissue incision, flap reflection, removal of soft and/or osseous tissue, complete removal of tooth and roots, and closure of the surgical site) OR submitted documentation (e.g., complete operative report, intraoral photos) supports the billed surgical code.

Surgical extraction definition and documentation requirements

Impaction levels: Impaction is classified and documented as soft tissue, partial bone, or complete bone impaction with corresponding required documentation (flap elevation and removal of bone for partial/complete bone impactions); special narrative support required for complete bone impactions with unusual complications (mandibular or maxillary specific considerations).

Impaction definitions and special considerations

Erupted third molars are not automatically surgical; surgical billing is supported only when documented root dilaceration/abnormality or a totally carious tooth prevents a purchase point and necessitates surgical technique as defined for surgical extraction.

Erupted third molar considerations

Residual roots: Surgical removal of residual tooth roots requires soft tissue incision, flap reflection and removal of bone with the root at least partially encased in bone; root tips lacking bony support should be reported as D7140 (non-surgical).

Residual root surgical criteria

Coronectomy may be appropriate (typically for lower third molars) when there is moderate to high risk to the inferior alveolar nerve documented by panoramic examination, possibly supplemented by cone beam CT; consider patient age and nerve-risk tolerance.

Coronectomy indications and imaging support

Coding

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 Actions & Documentation Requirements

Denial Risk

Denial Triggers

Removal of teeth is not benefited when the teeth do not present with an indicated clinical condition, are removed for patient or dentist convenience, or for cosmetic reasons. When any service is performed in conjunction with or in preparation for a non-covered or denied service, all related services are also not covered or will be denied.

Removal not benefited if no indicated clinical condition
Not covered when performed for convenience or cosmetic reasons
Related services to a denied service are also denied

Documentation Required

Clinical Documentation & Imaging Required

Appropriate diagnostic periapical or panoramic images must be submitted for all extractions. When surgical or impacted-tooth codes are billed, include the documentation that supports the procedure (e.g., complete operative report, intraoral photos, narrative clinical notes). If surgical extraction is billed but not evident from submitted information, a complete operative report is required to substantiate the code.

Diagnostic periapical or panoramic images required for all extractions
Operative report and/or intraoral photos required when surgical or impacted-tooth codes are billed
Narrative clinical notes should describe complications or anatomic involvement for impacted teeth

Documentation Required

Required Documentation and Supporting Evidence

Provider must document when an extraction meets criteria for surgical removal (soft tissue incision, flap reflection, removal of soft and/or osseous tissue, complete removal of tooth and roots, and closure). For impacted teeth, document impaction type (soft tissue, partial bone, complete bone) and any special considerations (e.g., proximity to mandibular canal or maxillary sinus, root involvement with adjacent structures, ramus obstruction, unusual tooth position). Coronectomy cases should include imaging that documents risk to the inferior alveolar nerve.

Surgical extraction requires documentation of incision, flap, bone removal, tooth/root removal, and closure
Specify impaction classification and provide supporting operative report or intraoral photos when not evident
Document special considerations for mandibular or maxillary impacted teeth (see criteria a–e)
Provide panoramic +/- cone beam CT for coronectomy cases to demonstrate nerve risk

Billing Rule

Provider Obligations & Billing Rules

If clinical records do not substantiate the billed CDT code (for example, surgical codes billed without evidence of incision, flap, bone removal, or operative report), the claim is subject to denial or request for additional documentation. Ensure submitted records clearly justify the level of service billed to avoid denial for insufficient documentation.

Surgical codes D7210–D7251 require supporting clinical documentation when not evident
D7140 should be used for root tips lacking bony support (not surgical)
Claims lacking adequate documentation will be denied or pended for records

Background

Extractions are indicated for symptomatic or pathologic conditions such as pain, dental caries, periodontal disease, periapical pathology, split tooth, tooth mobility, root resorption, infection, severe crown/root anomaly precluding restoration, traumatic injury, loss of pulp vitality secondary to infection, ectopic position causing damage, or teeth in the line of fracture. Impacted teeth that are not associated with pathology are not automatically pathologic; indications for extraction must be documented. Providers should supply appropriate diagnostic imaging and clinical documentation to demonstrate these indications.

Definitions

inv-10: Impacted tooth — definition of an impacted tooth

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

Clinical noteImpacted teeth may be soft tissue, partial bone, or complete bone impactions depending on crown coverage and position.

Documentation requirementWhen impaction status is not evident from submitted clinical information, appropriate supporting documentation (e.g., operative report, intraoral photos, radiographs) is required.

inv-11: Surgical extraction — definition describing soft tissue incision, flap reflection, osseous removal, full tooth/root removal

DefinitionA surgical extraction requires a 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 billing is requiredIf surgical extraction is not evident from submitted clinical information, documentation supporting the procedural code (e.g., a complete operative report) will be required.

Residual rootsSurgical extraction of residual tooth roots requires incision, flap reflection and removal of bone; roots must be partially encased in bone to qualify as surgical (otherwise report as D7140).

inv-12: Coronectomy — definition: intentional partial tooth removal for lower third molars when risk to inferior alveolar nerve

DefinitionCoronectomy is the intentional partial removal of a tooth (generally a lower third molar) where the crown is removed while roots are left in place to reduce risk to the inferior alveolar nerve.

IndicationOffered when there is a moderate to high risk of inferior alveolar nerve damage as documented on panoramic imaging, possibly supplemented by cone beam CT.

ConsiderationsMore appropriate in older individuals because they tolerate nerve damage less well; may occasionally be performed on lower second molars.