CurrentBlue Cross Blue Shield - WisconsinPolicy 07-101

Removal of Teeth (tooth extraction)

Defines clinical indications, documentation and coding guidance for erupted and impacted tooth extractions and when surgical techniques are required; applies to dental services reviewed under Blue Cross Blue Shield - Wisconsin contractual requirements.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyRemoval of Teeth (tooth extraction)

Policy CodePolicy 07-101

Change TypeNo material change

Effective DateJan 1, 2021

Next Review Date

Key ActionProvide appropriate diagnostic periapical or panoramic images for all extractions; when surgical extraction is claimed, include operative report or intraoral photos to support the procedure.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14criteria points

D7111,D7140,D7210-D7251example CDT codes

Imaging requiredimaging required

Coronectomycoronectomy guidance

Coverage Criteria — Removal of Teeth

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Medically Necessary Extraction Criteria

Covered when ALL of the following are met:

Clinical Indications: Extraction is indicated for pain, dental caries, periodontal disease, periapical pathology, cracked (split) tooth, tooth mobility, internal or external root resorption, infection, severe anomaly of the crown/root precluding 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 required for organ transplant/chemotherapy/radiation/prosthetic heart valve/joint replacement, or for orthodontic prophylaxis when clinically indicated.

Based on listed accepted clinical indications.

Imaging and Documentation: Appropriate diagnostic periapical or panoramic images must be provided for all extractions. When a surgical extraction is claimed, documentation (e.g., complete operative report, intraoral photos) must support soft tissue incision, flap reflection, removal of soft and/or osseous tissue, complete removal of tooth and roots, and closure of the surgical site.

Imaging required for all extractions; operative report may be required to substantiate surgical technique.

Impaction Type Requirements: Impacted teeth must be classified and documented as soft tissue impaction (crown partially/completely covered by soft tissue), partial bone impaction (crown not fully covered by bone requiring flap elevation and bone removal), or complete bone impaction (crown mostly/fully covered by bone requiring flap elevation and bone removal). For partial or complete bone impactions, documentation must demonstrate flap elevation and bone removal; special considerations (e.g., intimate root involvement with mandibular canal or adjacent roots, ramus obstruction, low position, access/angulation issues, proximity to maxillary sinus, tooth located above adjacent roots) may justify complex surgical codes when supported by clinical notes or narrative.

Preserve special considerations lists for mandibular and maxillary unusual complications.

Erupted Third Molars: Erupted third molars do not automatically qualify as surgical extractions. Surgical technique codes are appropriate only when documented clinical evidence (e.g., root dilaceration/abnormality or total caries precluding a purchase point) necessitates soft tissue incision, flap reflection, removal of soft and/or osseous tissue to access roots, creation of purchase points, complete removal of tooth and roots, and closure of the surgical site; otherwise the procedure is considered elective and should be reported as non-surgical extraction.

Surgical coding reserved for erupted third molars only when surgical criteria are met.

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

Document partial encasement in bone to qualify as surgical removal.

Coronectomy may be considered for lower (and occasionally second) molars when there is moderate-to-high risk of inferior alveolar nerve injury documented by panoramic exam, possibly supplemented by cone beam CT; coronectomy is typically for older individuals where nerve injury risk is less tolerable. When indicated and documented, coronectomy (D7251) may be reported.

Documentation of IAN proximity and risk required for coronectomy.

Surgical extraction procedure codes for erupted third molars are considered elective (not medically necessary) when there is no documented clinical evidence of root dilaceration/abnormality or total caries that eliminates a purchase point. Absent documentation that soft tissue incision, flap reflection, and removal of soft and/or osseous tissue were required to access and completely remove the tooth and roots, report non-surgical extraction codes rather than surgical codes.

When root tips lack bony support they should be reported as D7140 rather than surgical codes; conversely, retained roots that are partially encased in bone may qualify as surgical removals when documentation supports bone removal to create purchase points.

Coding Guidance

Example CDT / Dental Procedure Codesmixed

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; may include elevation of mucoperiosteal flap
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

ICD-10-CM Diagnosis Codes (examples)ICD-10

K08.1	Loss of teeth due to trauma, extraction, or local periodontal disease (example: retained root)
K08.4	Partial loss of teeth (includes retained roots)
K00.6	Disturbances in tooth formation (used when congenital conditions relevant)
K08.8	Other specified disorders of teeth and supporting structures
K01.1	Impacted tooth
K04.7	Periapical abscess without sinus
K08.9	Disorder of tooth and supporting structures, unspecified

Provider Actions and Requirements

Prior Authorization

Pre-service Review Requirement

Contact the plan/customer service to determine if pre-service review or prior authorization is required before performing extractions or related surgical dental procedures. Requirements may vary by line of business and contract.

Step Therapy

Plan-dependent Step Considerations

Some plans require that impacted third molars be symptomatic or demonstrably pathologic to qualify for coverage. Plan design may vary; 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 depending on the plan.

Denial Risk

Denial Triggers

Removal of teeth is not benefited if there is no accepted clinical indication, if performed 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, all related services are also not covered or denied.

Background

Extractions are supported when clinical indications are present, such as pain, dental caries, periodontal disease, periapical pathology, cracked tooth, tooth mobility, root resorption, infection, traumatic injury, loss of pulp vitality due to infection, ectopic position causing damage, teeth in line of fracture, or when prophylactic removal is clinically required (for example, prior to organ transplant, chemotherapy, radiation, prosthetic heart valve placement, or as part of orthodontic treatment).

Impacted teeth are considered pathologic only when associated pathology exists; impacted third molars that are symptomatic or pathologic are typically covered, while asymptomatic impacted third molars may be subject to plan-dependent benefit rules.

Surgical extractions require documentation that justifies the use of surgical technique — appropriate diagnostic periapical or panoramic imaging for all extractions and, when a surgical extraction is claimed, operative details (operative report and/or intraoral photos) demonstrating soft tissue incision, flap reflection, and removal of soft and/or osseous tissue to access and remove tooth and roots with closure of the surgical site.

Specific procedures such as coronectomy may be considered for lower third molars with moderate to high risk of inferior alveolar nerve injury documented on panoramic imaging or cone beam CT, and retained or partially encased roots may necessitate surgical removal when bone removal is required.

Key Definitions

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; an impacted tooth is not considered pathologic unless associated pathology is present.

Clinical noteImpaction is about eruption obstruction (position/anatomic impingement) rather than automatic pathology.

DocumentationImaging (periapical or panoramic) and clinical notes should demonstrate the impaction and any associated pathology when present.

Surgical extraction

DefinitionA procedure 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.

Coding/documentationWhen surgical extraction is not evident from submitted clinical information, a complete operative report (and/or intraoral photos) will be required to support the procedural code.

Clinical implicationSurgical technique is dictated by tooth position or root formation that requires incision, flap, and bone removal rather than simple elevation/forceps removal.

Soft tissue impaction

DefinitionRemoval of a tooth where the crown is not fully erupted into the oral cavity and is partially or completely covered by soft tissue; these are generally located below the level of occlusion.

Procedure requirementIf soft tissue impaction is not evident from documentation, provide operative report or intraoral photos to substantiate the procedure code.

Clinical locationSoft tissue impacted teeth are generally below the occlusal plane.

Partial bone impaction

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

Clinical featuresPartial bone impactions are generally submerged relative to adjacent teeth where bone level prevents adequate purchase of instruments.

DocumentationWhen not evident from submitted documentation, provide a complete operative report or intraoral photos to support the procedural code.

Complete bone impaction

DefinitionRemoval of a tooth where the crown is mostly or fully covered by bone; the procedure requires flap elevation and removal of bone.

Special considerationsComplete bone impactions may have unusual complications (e.g., intimate root involvement with mandibular canal or proximity to sinus) that justify complex surgical coding when documented.

DocumentationIf complete bone impaction is not evident from submitted clinical documentation, provide a complete operative report or intraoral photos to substantiate the procedural code.