CurrentAnthemPolicy 07-101

Removal of Teeth

Governs clinical review and coverage considerations for removal (extraction) of erupted and impacted teeth under Anthem dental plans; applies to providers requesting benefits and utilization review for dental extractions.

Policy Summary

PayerAnthem

PolicyRemoval of Teeth

Policy CodePolicy 07-101

Change TypeNo material changes

Effective Date01/01/2022

Next Review Date

Key ActionProvide appropriate diagnostic periapical or panoramic images for all extractions and supply operative reports or intraoral photos when surgical indication is not evident.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

16document chunks

12listed CDT/Procedure codes

2022-01-01policy publish date

Coverage and Medical Necessity Criteria

Medical Necessity Criteria

Covered when ALL of the following are met

Policy Summary

PayerAnthem

PolicyRemoval of Teeth

Policy CodePolicy 07-101

Change TypeNo material changes

Effective Date01/01/2022

Next Review Date

Key ActionProvide appropriate diagnostic periapical or panoramic images for all extractions and supply operative reports or intraoral photos when surgical indication is not evident.

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.

Basic clinical indications: Tooth presents with 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 prosthetic or restorative treatment, traumatic injury to teeth, loss of pulp vitality typically secondary to infection, ectopic position causing damage to other teeth, teeth in the line of fracture, or prophylactic removal when medically necessary (e.g., prior to organ transplant, chemotherapy, radiation therapy, prosthetic heart valve replacement, joint replacement) or for orthodontic purposes.

Special Considerations

Coverage nuances and special procedures

Third molar and coronectomy guidance: Erupted third molars do not automatically qualify as surgical extractions and most do not require special surgical techniques. Surgical coding for third molars requires documented clinical evidence such as root dilaceration/abnormality or a totally carious tooth preventing a purchase point and necessitating soft tissue incision, flap reflection, bone removal and/or sectioning with complete removal of tooth and roots. Coronectomy (intentional partial tooth removal) may be appropriate for lower third molars at moderate to high risk of inferior alveolar nerve injury; supporting imaging (panoramic and/or cone beam CT) should be documented and coronectomy is more appropriate in older individuals.

Residual roots: Surgical extraction of residual tooth roots requires incision of soft tissue, reflection and removal of bone to access the root(s) to create purchase points. Root tips lacking bony support should be reported as a non-surgical extraction (D7140).

Procedure and Diagnosis Codes

Covered CDT Procedure Codes (informational listing)CPT | 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

Diagnosis codesICD-10

ICD-10-CM

Diagnoses for dental diseases and conditions: see the current CDT code book for details

Documentation, Submission and Denial Triggers

Documentation Required

Documentation-supported procedure review

Documentation-supported procedure review — surgical removal codes require documentation demonstrating surgical indication. When surgical extraction is billed, submit a complete operative report and diagnostic images (periapical or panoramic) showing the clinical indications (e.g., soft tissue incision, flap reflection, removal of soft and/or osseous tissue, removal of tooth and roots, and closure). If submitted clinical information does not clearly demonstrate a surgical procedure, the service will be reviewed as non-surgical and may be denied or re-coded accordingly.

Required: complete operative report when surgical technique is claimed
Required: diagnostic periapical or panoramic images for all extractions
When surgical technique is not evident, the plan will require additional documentation (operative report, intraoral photos) to support surgical codes

Note

Provider action: submit supporting clinical narrative and images

Provider action highlight — submit clear, specific clinical documentation with claims to avoid denials or requests for additional information. Include narrative clinical notes describing symptoms or pathology (infection, non-restorable carious destruction, root dilaceration, intimate involvement with mandibular canal or adjacent roots, proximity to maxillary sinus, obstruction by ramus, unusual position or angulation) when these are the basis for surgical removal.

Include clinical notes/narrative describing symptomatic or pathologic findings when billing for impacted or bone-impacted teeth
For third molars, document root abnormalities or inability to obtain purchase point if claiming surgical extraction
Provide intraoral photos when soft tissue or bone impaction is claimed but not otherwise evident

Documentation Required

Required documentation

Required documentation — diagnostic periapical or panoramic images are required for all extractions. For soft tissue, partial bone, or complete bone impactions, provide operative reports and intraoral photos as needed to demonstrate flap elevation, bone removal, and other surgical steps. Residual root surgical extractions must include documentation of soft tissue incision, reflection, and bone removal to create purchase points.

Diagnostic images (periapical or panoramic) required for all extractions
Complete operative report required to support surgical extraction codes (describe incision, flap, bone removal, tooth/root removal, closure)
Intraoral photos recommended/required when clinical documentation does not clearly show impaction type or surgical technique
For residual roots, documentation must show bone removal to allow access to retained root(s) (report D7140 when applicable)

Denial Risk

Coverage/Deny triggers

Coverage/Deny triggers — services will be denied or considered not benefited when teeth do not present one of the listed clinical indications, when extractions are for patient or dentist convenience, or when billed as surgical without supporting documentation. When a service is performed in conjunction with or preparation for a non-covered/denied service, related services are also not covered or denied.

Denial/Not benefited if tooth lacks documented symptomatic or pathologic indication
Denial/Not benefited if extraction is for convenience or cosmetic reasons
Denial or reclassification if surgical codes lack supporting operative report and images
Related services performed with a non-covered service are also not covered

Background and Indications

Indications for removal (extraction) of teeth include common clinical problems such as pain, dental caries, periodontal disease, and periapical pathology. Other supported indications include a cracked tooth, significant tooth mobility, root resorption, local or systemic infection, severe crown or root anomalies that preclude restoration, traumatic injury, loss of pulp vitality from infection, ectopic tooth position causing damage, teeth that are in the line of a facial fracture, and prophylactic removal when medically indicated (for specified medical therapies or orthodontic reasons). Documentation of these clinical findings and appropriate diagnostic imaging are required to support coverage.

Key Definitions

Impaction categories

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

Soft tissue impactionCrown partially or completely covered by soft tissue; generally located below the level of occlusion; may require documentation (operative report, intraoral photos) if not evident.

Partial bone impactionCrown not fully covered by bone; procedure requires flap elevation and removal of bone; adjacent bone level that prevents adequate instrument purchase may necessitate documentation.

Complete bone impactionCrown mostly or fully covered by bone; requires flap elevation and removal of bone; special considerations include intimate root relationship with mandibular canal or adjacent roots, ramus obstruction, unfavorable angulation, or proximity to maxillary sinus.

Surgical extraction

Core definitionSurgical extraction requires a soft tissue incision, reflection, removal of soft and/or osseous (bone) tissue, complete removal of the tooth and roots, and closure of the surgical site.

When surgical coding appliesAn extraction of a fully erupted tooth may be considered surgical if tooth position or root formation dictates surgical removal (e.g., inability to obtain a purchase point, root dilacerations/abnormality).

Documentation requirementWhen surgical extraction is not evident from submitted clinical information, a complete operative report or other supporting documentation (intraoral photos, imaging) is required to justify the procedural code.

Residual rootsSurgical extraction of residual roots requires incision, reflection and bone removal to create purchase points; root tips lacking bony support should be reported as D7140 rather than a surgical-root code.

Coronectomy

Procedure descriptionCoronectomy (intentional partial tooth removal): removal of the crown portion while retaining roots, most commonly performed on lower third molars to reduce risk to the inferior alveolar nerve.

IndicationsOffered when there is a moderate to high risk of inferior alveolar nerve damage documented by panoramic examination and possibly supplemented by cone beam CT.

Typical patient considerationsMore appropriate in older individuals because they tolerate nerve damage less well; occasionally performed on lower second molars in select situations.

Supporting documentationPanoramic imaging and/or cone beam CT findings supporting proximity to the inferior alveolar nerve should be documented when coronectomy is considered.