CurrentBlue Cross Blue Shield - WisconsinPolicy 07-101

Removal of Teeth (Tooth Extractions)

This policy governs medical necessity and coding for surgical and non-surgical removal of teeth for Blue Cross Blue Shield - Wisconsin members, including erupted, impacted, residual roots, and coronectomy procedures. It affects dentists, oral surgeons, and other providers performing extractions and the plan's benefit determinations.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyRemoval of Teeth (Tooth Extractions)

Policy CodePolicy 07-101

Change TypeNo material changes

Effective Date

Next Review DateOct 30, 2025

Key ActionProvide current (within 12 months), dated pretreatment periapical or panoramic images and document clinical indications when submitting for authorization or claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥12 moRadiograph recency (max)

D7140–D7252Key CDT codes

Symptomatic/pathologicImpacted third molar rule

01/01/2026Publish date

Coverage Criteria — Removal of Teeth

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.

General Coverage Criteria for Extractions

Covered when ALL of the following are met

Imaging: Current (within 12 months), dated, diagnostic pretreatment periapical or panoramic images must be provided for all extractions.within 12 months

Clinical indication: Tooth demonstrates one or more accepted clinical indications such as pain, dental caries, periodontal disease, periapical pathology, split/cracked tooth, mobility, root resorption, infection, severe crown/root anomaly precluding restoration, traumatic injury, loss of pulp vitality secondary to infection, ectopic position causing harm, teeth in line of jaw fracture, or prophylactic removal necessitated by organ transplant/chemotherapy/radiation/prosthetic valve/joint replacement or orthodontic purposes.N/A

Appropriate coding and procedure selection: The selected CDT code must accurately reflect the tooth position and procedure performed (e.g., D7140 for erupted tooth or exposed root; D7210 for erupted requiring removal of bone and/or sectioning and possible flap; D7220 for removal of impacted tooth - soft tissue; D7230 for partially bony impacted; D7240 for completely bony impacted; D7241 for completely bony with unusual surgical complications; D7250 for residual roots; D7251 for coronectomy; D7252 for partial extraction for immediate implant placement).N/A

Impacted third molar plan-dependent requirement: When a third molar is bone impacted, some plans require it to be symptomatic or pathologic to qualify for benefits; if symptomatic or pathologic, benefits might be available to remove the opposing asymptomatic, non-pathologic third molar on the same date of service depending on plan design.N/A

D7241 unusual complications: For D7241 (removal of completely bony impacted tooth with unusual surgical complications), special consideration may be made when clinical notes/narrative document intimate involvement with the mandibular canal or adjacent tooth roots, mandibular ramus obstructing eruption/access, unusually low tooth position, access/angulation that risks injury to adjacent tooth, or (for maxillary teeth) proximity to the maxillary sinus or location above adjacent roots.N/A

Removal of teeth is not benefited when the tooth does not meet an accepted clinical indication. Indications that justify benefit include pain, dental caries, periodontal disease, periapical pathology, split/cracked 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 to other teeth, teeth in the line of a jaw fracture, or prophylactic removal required for organ transplant, chemotherapy, radiation therapy, prosthetic heart valve or joint replacement, or orthodontic purposes.

For impacted third molars, coverage depends on plan design: while many plans cover removal of symptomatic or pathologic erupted or bone-impacted third molars, some plans require bone-impacted third molars to be symptomatic or pathologic to qualify for benefits. When a third molar is symptomatic or pathologic, benefits may—depending on the plan—also be available to remove the opposing, asymptomatic third molar on the same date of service.

Applicable Procedure Codes

Applicable CDT Procedure CodesCPT

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
D7252	Partial extraction for immediate implant placement

Provider Documentation, Submission, and Billing Notes

Denial Risk

Benefit exclusion and cascade denial

Removal of teeth is contractually not benefited if the teeth do not present 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 restorative treatment, traumatic injury, loss of pulp vitality secondary to infection, ectopic position causing damage, teeth in line of jaw fracture, or prophylactic removal necessitated by organ transplant, chemotherapy, radiation therapy, prosthetic heart valve replacement, joint replacement, or orthodontic treatment. Teeth removed for patient or provider convenience or cosmetic reasons are not benefited.

Benefit exclusion applies when no clinical indication (e.g., pain, caries, periodontal disease, pathology).
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 are denied (cascade denial).

Documentation Required

Required imaging

Current (within 12 months), dated diagnostic pretreatment periapical or panoramic images must be provided for all extractions.

Imaging must be dated and part of the submission for benefit determination (<12 months).

Documentation Required

Documentation for D7241 with unusual complications

D7241 (Removal of impacted tooth—completely bony, with unusual surgical complications) will only be considered when clinical notes and/or narrative documentation substantiate the unusual complications. Documentation should specifically describe the complicating factors and how they affected the surgical approach or risk.

Mandibular examples include intimate involvement of tooth roots with the mandibular canal; intimate involvement with adjacent tooth roots; obstruction by the mandibular ramus; tooth unusually low relative to adjacent molar; access/angulation that risks injury to adjacent tooth.
Maxillary examples include proximity to the maxillary sinus or a position above and angular to adjacent tooth roots.
Clinical notes/narrative must clearly state the complication(s) and correlate with imaging and operative findings.

Billing Rule

Coding-specific documentation note

Coding must reflect the actual clinical procedure performed and must be supported by documentation. Extraction of fully erupted primary teeth submitted without the standard codes (D7111 or D7140) or other atypical coding will require supporting clinical documentation for benefit determination.

Select codes based on tooth position and surgical technique (e.g., D7140, D7210, D7220–D7241, D7250–D7252).
If submitting D7241, include narrative and imaging as described above.
Extraction of fully erupted primary teeth not billed with D7111 or D7140 requires supporting documentation.

Background — Surgical and Non-Surgical Extractions

A surgical extraction removes a tooth from its socket and frequently involves additional procedures based on tooth position and complexity, such as elevation of a mucoperiosteal flap, removal of bone, tooth sectioning, and closure. Surgical technique and coding should reflect the tooth’s presentation (erupted versus soft-tissue or bony impacted) and the clinical indication for removal. Indications for extraction include the clinical reasons listed above (e.g., pain, infection, structural compromise, mobility, resorption, trauma, or conditions that interfere with other medical treatments); services performed in conjunction with or to prepare for a non-covered service are also not covered.

Definitions

Surgical extraction — definition and key attributes

DefinitionRemoval of a tooth from its socket within the jawbone that may require incisions, bone removal, and specialized instruments (used for impaction, severe damage, or complex anatomy).

Included procedural stepsMay include mucoperiosteal flap elevation, cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone, and closure depending on complexity.

Typical indications for surgical techniqueUsed when tooth position, impaction, severe structural damage, or complex anatomic considerations prevent simple elevation/forceps removal.

Coding note (most actionable)Select CDT code that reflects surgical complexity (e.g., D7210 for erupted requiring bone removal/sectioning; D7220–D7241 for impacted categories); documentation and appropriate imaging must be provided.

Supporting documentationCurrent (within 12 months), dated diagnostic pretreatment periapical or panoramic images are required for all extractions.

Impacted tooth — definition

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

Coverage implicationRemoval of an impacted tooth may not be benefited unless there is associated pathology or plan-specific symptomatic/pathologic requirements are met.

Related CDT categoriesImpacted tooth removal codes include D7220 (soft tissue), D7230 (partially bony), D7240 (completely bony), and D7241 (completely bony with unusual surgical complications).