RetiredAnthemPolicy 07-201

Removal of Third Molar Teeth

Clinical guideline governing when extraction of third molar (wisdom) teeth is considered medically/dentally necessary and what documentation and coding support is required; applies to Anthem dental plan utilization review and providers submitting claims.

Policy Summary

PayerAnthem

PolicyRemoval of Third Molar Teeth

Policy CodePolicy 07-201

Change TypeNo material changes (archived)

Effective DateJan 1, 2022

Next Review Date

Key ActionProvide appropriate diagnostic periapical or panoramic images and operative reports or intraoral photos when surgical extraction codes are billed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11Clinical criteria items

D7140-D7251Representative CDT codes

11/11/2022Archive status date

Coverage Criteria for Third Molar Extractions

Medically Necessary Extraction Criteria

Covered when ALL of the following are met for the specific tooth:

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 indications: Tooth presents with 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 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 medically indicated (e.g., organ transplant, chemotherapy, radiation, prosthetic heart valve, joint replacement) or for orthodontic reasons.

Each individual tooth must have documented details of symptoms or pathology; dental review must reflect generally accepted standards of dental practice.

Imaging and documentation: Appropriate diagnostic periapical or panoramic images are provided for the extraction; when surgical extraction procedure codes are billed, a complete operative report and/or intraoral photos documenting soft tissue incision, flap reflection, bone removal, root purchase points, and closure must be supplied.

See coding/documentation requirements; lack of surgical documentation may render a surgical code elective.

Impaction and surgical complexity: Classification of impaction (soft tissue, partial bone, complete bone) with supporting clinical documentation is required; special considerations for complex surgical codes (e.g., intimate root relationship to mandibular canal or adjacent tooth, obstructing ramus, unusual depth or angulation, proximity to maxillary sinus) must be documented in clinical notes or narrative.

Coronectomy (D7251) may be appropriate when risk to the inferior alveolar nerve is evident on imaging; surgical technique must be supported by operative report when claimed.

Referenced Codes and Coding Guidance

Referenced CDT CodesCDT

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

Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization and Documentation Requirement

Prior authorization/medical review is required. Documentation must include clinical indications and relevant imaging to support medical necessity for third molar removal.

Provide diagnostic periapical or panoramic images for all extractions.
When surgical extraction is billed, submit a complete operative report documenting soft tissue incision, flap reflection, removal of soft and/or osseous tissue, complete removal of tooth and roots, and closure of the surgical site.

Step Therapy

Plan‑Specific Coverage Considerations

Some plans require that impacted third molars be symptomatic or pathologic to be covered. Symptoms or pathology must be documented for each individual tooth; when one third molar is symptomatic/pathologic, plan design may allow coverage for removal of an opposing asymptomatic, non‑pathologic third molar on the same date of service.

Benefits for bone‑impacted third molars may be limited to symptomatic or pathologic teeth per plan contract.
Provide supporting clinical notes/narrative detailing symptoms or pathology for each tooth.
Examples of special surgical considerations (mandibular canal involvement, proximity to sinus, unusual angulation) should be documented when applicable.

Denial Risk

Coverage Denial Triggers

Removal is not benefited if no listed clinical indication is present, or if performed for patient/dentist convenience or cosmetic reasons. When a service is performed in conjunction with a non‑covered or denied service, related services are also not covered.

Denial likely if clinical indications (symptoms, pathology, or surgical necessity) are not documented.
Related services performed for or with a non‑covered extraction will also be denied.
Erupted third molars without documented surgical necessity (e.g., no root abnormality, no need for flap/bone removal) are considered elective and may be non‑benefited.

Background and Clinical Indications

Indications for tooth removal include clinical problems such as pain, dental caries, periodontal disease, periapical pathology, fracture, mobility, resorption, infection, non-restorable anomalies, traumatic injury, loss of pulp vitality, ectopic position, and prophylactic removal for certain medical or orthodontic reasons. Impacted teeth are not considered pathologic solely for their position unless associated pathology is documented.

Definitions

Impacted tooth — definition

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

Clinical noteImpacted teeth may be soft tissue, partial bone, or complete bone impactions; documentation should describe the type of impaction.

Coverage implicationAn impacted tooth alone is not pathologic and requires associated pathology or listed clinical indications to be considered medically necessary for extraction.

Imaging requirementAppropriate diagnostic periapical or panoramic images must be provided for all extractions to document impaction and associated pathology.

Surgical extraction — definition

DefinitionAn extraction requiring 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.

Operative documentationWhen surgical extraction is claimed, a complete operative report and/or intraoral photos describing incision, flap reflection, bone removal, root purchase points, and closure may be required to support the procedure code.

When erupted tooth is surgicalA fully erupted tooth may be considered surgical if the position of the tooth or the formation of the root dictates a surgical removal.

Coding supportIf surgical technique is not evident from submitted clinical information, appropriate documentation supporting the procedural code will be required.

Revision History

2022-11-11archivedLatest

Policy archived and combined with policy 07-101.

2021-10-30review

Annual clinical review completed by Committee (last review prior to archiving).

2020-12-05review

Annual review conducted by Committee.

2020-12-02created

Initial policy version published.