RetiredAnthemPolicy 07-201

Removal of Third Molar Teeth

Clinical/dental policy governing when removal (extraction) of third molar teeth is considered medically/dentally necessary and contractual coverage considerations for Anthem members. Affects dentists and plan reviewers assessing benefit coverage for third molar extractions.

Policy Summary

PayerAnthem

PolicyRemoval of Third Molar Teeth

Policy CodePolicy 07-201

Change TypeArchived (no material changes)

Effective DateJan 1, 2022

Next Review Date

Key ActionProvide appropriate diagnostic periapical or panoramic images and supporting operative documentation when surgical extraction is claimed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CDT 6+procedure codes provided

Archivedpolicy status

Radiographs requireddiagnostic imaging requirement

Coronectomyspecial procedure noted

Coverage Criteria for Third Molar Removal

Medically/Dentally Necessary Extractions

Policy Summary

PayerAnthem

PolicyRemoval of Third Molar Teeth

Policy CodePolicy 07-201

Change TypeArchived (no material changes)

Effective DateJan 1, 2022

Next Review Date

Key ActionProvide appropriate diagnostic periapical or panoramic images and supporting operative documentation when surgical extraction is claimed.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Primary clinical indications: Extraction is for an accepted clinical indication such as pain, dental caries, periodontal disease, periapical pathology, split tooth (cracked tooth), tooth mobility, internal or external root resorption, infection, severe crown/root anomaly precluding prosthetic/restorative treatment, traumatic injury, loss of pulp vitality typically secondary to infection, ectopic position causing damage to other teeth, teeth in the line of fracture, prophylactic removal necessitated by systemic therapy (e.g., organ transplant, chemotherapy, radiation) or for orthodontic reasons.

Documentation and imaging: Appropriate diagnostic periapical or panoramic images are provided. When a surgical extraction is claimed, documentation (e.g., complete operative report or intraoral photos) must demonstrate the need for surgical technique (soft tissue incision/flap reflection, removal of soft and/or osseous tissue, tooth/root removal, and closure of the surgical site).

Impaction and pathology: An impacted third molar is considered pathologic only when associated pathology or symptoms are documented; an impacted tooth alone is not pathologic. Details of symptoms or pathology must be indicated for each individual tooth. Dependent on plan design, when one third molar is symptomatic or pathologic, removal of the opposing asymptomatic non‑pathologic third molar on the same date of service may be covered per contract provisions.

Special complications requiring supporting notes: Unusual anatomic or surgical complications (for example: intimate involvement of tooth roots with the mandibular canal, intimate root involvement with roots of adjacent tooth, mandibular ramus obstructing access, tooth unusually low relative to adjacent molar, access/angulation that complicates removal, proximity to the maxillary sinus, or root dilaceration) require clinical notes and/or narrative support to justify the surgical approach.

Extractions performed solely for patient or dentist convenience or for cosmetic reasons are not contractually benefited. When a tooth does not meet one of the policy's listed clinical indications, removal is not considered a covered service.

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 denied. Plan review evaluates removals to determine whether submitted services meet generally accepted standards of dental care and contractual benefit requirements; documentation supporting medical necessity should be provided.

An erupted third molar does not automatically qualify as a surgical extraction and, in most cases, does not require surgical technique. Erupted third molars without documented symptoms, pathology, or surgical necessity are generally not considered surgical extractions and are not contractually benefited absent supporting clinical evidence.

Surgical extraction of an erupted tooth requires documentation that soft tissue incision/flap reflection, removal of soft and/or osseous tissue, sectioning or other measures were necessary to access and completely remove the tooth and roots. Without such documentation (for example, radiographic evidence or an operative report), claims for surgical extraction of an erupted third molar will generally be non-covered.

Procedure Codes

Covered CDT Codes (listed for informational purposes)CDT

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
D7251	Coronectomy intentional partial tooth removal

Provider Requirements and Impact

Prior Authorization

Prior review / benefit determination

The plan performs prior review/benefit determination for third molar removals to ensure requested services meet contractual requirements and generally accepted standards of dental care. A determination that a service is medically/dentally necessary does not guarantee it is a covered benefit under the dental plan.

Plan review evaluates removals to determine whether services meet contractual and clinical standards
Medically/dentally necessary does not automatically equal covered benefit

Note

Documentation Required

Required documentation

Appropriate diagnostic periapical or panoramic images must be provided for all extractions. When a surgical extraction is not evident from submitted clinical information, additional documentation such as a complete operative report, intraoral photos, or narrative must be provided to support the procedural code submitted. For soft tissue, partial bone, or complete bone impactions, documentation should demonstrate the findings that justify the chosen surgical code (e.g., flap reflection, bone removal, access issues).

Provide periapical or panoramic images with all extraction requests
If surgical extraction is billed, submit operative report and/or intraoral photos when surgical steps are not evident
For soft tissue, partial bone, or complete bone impactions, include documentation of the specific clinical findings and procedures performed

Documentation Required

Complication documentation

Special complication documentation is required when unusual anatomic relationships or complications are present. Clinical notes and narrative must support claims of intimate root involvement with the mandibular canal or adjacent tooth roots, obstruction by the mandibular ramus, unusually low tooth position, difficult access/angulation risking adjacent tooth injury, or proximity to the maxillary sinus. Without such documentation, surgical procedure codes for complicated extractions may be denied or downgraded.

Document intimate root involvement with the mandibular canal
Document intimate root involvement with roots of adjacent tooth
Document mandibular ramus obstruction, unusually low tooth position, or difficult access/angulation
Document proximity to the maxillary sinus for maxillary impactions

Denial Risk

Coverage denial triggers

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

Teeth without listed clinical indications are not covered
Extractions for convenience or cosmetic reasons are not covered
Services performed with or in preparation for a non-covered/denied service are also not covered

Background and Clinical Indications

Indications for tooth extraction include pain, dental caries, periodontal disease, periapical pathology, split or fractured tooth, tooth mobility, internal or external root resorption, infection, severe crown/root anomaly precluding restoration, traumatic injury, loss of pulp vitality from infection, ectopic position causing damage, teeth in the line of a fracture, and prophylactic removal related to systemic therapy or for orthodontic reasons. An impacted tooth is not considered pathologic unless associated pathology or symptoms are present.

For impacted teeth or extractions claimed as surgical, supporting documentation such as appropriate diagnostic periapical or panoramic images and, when necessary, an operative report or intraoral photos should be submitted to demonstrate the clinical indication and the need for surgical technique.

Definitions

Surgical extraction — definition and key characteristics

DefinitionProcedure requiring 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 considered surgicalAn extraction of a fully erupted tooth may be considered surgical if tooth position or root formation dictates surgical removal (e.g., requires flap elevation, bone removal, sectioning).

Documentation requirementIf surgical extraction is not evident from submitted clinical information, a complete operative report or equivalent documentation will be required.

Impacted tooth — definition

DefinitionA tooth that cannot fully erupt into function due to abnormal position or impingement of other anatomic structures that block the normal eruption pathway.

Pathology noteAn impacted tooth is not considered pathologic unless pathology is associated with it.

Clinical implicationImpaction describes eruption inability and does not alone indicate surgical necessity without associated symptoms or pathology.

Soft tissue impaction — key characteristics

DefinitionExtraction where the crown is not fully erupted into the oral cavity and is partially or completely covered by soft tissue.

Typical locationSoft tissue impacted teeth are generally located below the level of occlusion.

Documentation requirementWhen soft tissue extraction is not evident from submitted documentation, a complete operative report or intraoral photos may be required to support the procedural code.

Partial bone impaction — key characteristics

DefinitionRemoval of a tooth where the crown is not fully covered by bone and requires flap elevation and limited bone removal.

Surgical actionsProcedure requires flap elevation and may require limited bone removal to gain access; adjacent bone level can affect instrument purchase.

Documentation requirementIf partial bone impaction is not evident from submitted clinical documentation, a complete operative report or intraoral photos may be required.

Complete bone impaction — key characteristics

DefinitionRemoval of a tooth in which the crown is mostly or fully covered by bone and the procedure requires elevation and removal of bone.

Surgical actionsRequires flap elevation and removal of bone to expose and remove the tooth and roots.

Documentation requirementWhen a complete bone extraction is not evident from submitted clinical documentation, appropriate documentation (e.g., operative report) will be required.

Revision History

2022-11-11archivedLatest

Policy archived (status set to Archived).

2022-01-01published

Policy published with clinical criteria for removal of third molar teeth (Guidelines #07-201).

2021-10-30reviewed

Annual review completed by Committee (last review date recorded).

2020-12-05annual_review

Annual review completed by Committee (revision entry).

2020-12-02initial_revision

Initial version/revision recorded (committee).