ModifiedCignaPolicy 0586

Alveoloplasty (CPT 41874) Coverage Criteria

Defines coverage criteria for alveoloplasty (CPT 41874) under Cigna-administered health benefit plans and explains when the procedure is considered medically necessary or not medically necessary.

Policy Summary

PayerCigna

PolicyAlveoloplasty (CPT 41874) Coverage Criteria

Policy CodePolicy 0586

Change TypeNew policy statement (initial review)

Effective Date12/01/2025

Next Review DateSep 15, 2026

Key ActionSubmit prior authorization and supporting documentation showing one of the medical necessity criteria is met for CPT 41874.

SourceLink

POLICY UPDATE CHANGES

New policy statement.

41874Primary procedure code addressed

12 monthsAccidental injury timeframe

24 monthsOral cancer replacement timeframe

12/01/2025Policy effective date

7 pagesDocument length

Coverage and Medical Necessity Criteria

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Medically Necessary Criteria (CPT 41874)

Covered when ANY of the following are met

Alveoloplasty medical necessity criteria

Individual with a congenital defect or developmental malformation which interferes with function.
Following an accidental injury to sound natural teeth that occurs after the date of coverage within 12 months of the loss of natural teeth; note: chewing injuries are not considered accidental injuries.
Loss of natural teeth due to oral cancer which interferes with function, where the loss occurred while covered under the plan and replacement occurs within 24 months of the loss of natural teeth.
When provided in preparation for, or in the course of, treatment (e.g., radiation, chemotherapy) for head and neck cancer.

Medical Necessity

Covered when the applicable policy criteria are met

Alveoloplasty (CPT 41874) is considered medically necessary when criteria in the applicable policy statements listed in the full policy are met.

Verify code currency; deleted or inactive CPT codes at the time of service may not be eligible for reimbursement.

Alveoloplasty is considered NOT medically necessary for any indication other than those explicitly listed in the medical necessity criteria. Examples of non-covered indications include, but are not limited to, procedures performed solely for extraction of impacted wisdom teeth.

Services billed with CPT codes that have been deleted or are not effective at the time the service is rendered may not be eligible for reimbursement. The policy’s code list may not be exhaustive due to AMA/CMS updates; providers should verify code currency prior to billing.

Any clinical indication that is not explicitly listed in the policy’s medical necessity criteria is considered not medically necessary. For example, alveoloplasty performed solely in conjunction with wisdom teeth extraction is not covered.

Procedure Codes, Timeframes, and Code Lists

Considered Medically Necessary when criteria metCPTCovered

41874

Alveoloplasty, each quadrant (specify)

Considered Medically Necessary when criteria metCPTCovered

41874

Alveoloplasty, each quadrant (specify)

Accidental injury timeframe (inv-08)

TimeframeLoss of natural teeth due to accidental injury must occur within 12 months of the loss to meet coverage criteria.

ScopeApplies only when the accidental injury to sound natural teeth occurs after the date of coverage.

ExclusionChewing injuries are not considered accidental injuries for this timeframe.

Oral cancer replacement timeframe (inv-09)

TimeframeReplacement of natural teeth lost due to oral cancer must occur within 24 months of the loss to be eligible for coverage.

Coverage conditionTo be eligible, the loss of teeth must have occurred while the member was covered under the plan.

Clinical contextApplies when tooth loss due to oral cancer interferes with function.

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization / Medical Necessity Requirement

If benefits are available under the member's plan, CPT 41874 (alveoloplasty, each quadrant) is covered only when the policy's stated medical necessity criteria are met. Providers must verify Medicare/plan-specific prior authorization requirements and member benefits before rendering services.

Prior authorization may be required—confirm with the member's plan prior to scheduling.
Use and submit the most appropriate and covered diagnosis and procedure codes for the service rendered.

Prior Authorization

Prior Authorization Expectation for CPT 41874

Alveoloplasty (CPT 41874) is considered medically necessary only when the policy's applicable criteria are met. Providers should verify Medicare and plan-specific coverage and prior authorization expectations before providing or billing for services.

Confirm that the service meets one of the listed medical necessity criteria in the Coverage Policy.
Check for any applicable Medicare NCD/LCD updates that may affect coverage.

Denial Risk

Providers must submit the most appropriate and covered diagnosis and procedure codes. Claims for services billed with codes that are not covered under the applicable Coverage Policy will be denied.

Claims submitted for services not accompanied by covered codes under the applicable Coverage Policy will be denied.
When billing, use the most appropriate codes effective as of the date of submission.

Documentation Required

Code Currency and Documentation

Services must be billed using CPT codes that are current and effective on the date of service. Deleted or inactive CPT codes at the time the service is rendered may not be eligible for reimbursement.

Deleted codes and codes which are not effective at the time the service is rendered may not be eligible for reimbursement.
The CPT code list in the policy may not be all-inclusive; verify AMA/CMS code updates.

Billing Rule

Not Medically Necessary for Other Indications

Alveoloplasty is considered NOT medically necessary for indications other than those specifically listed (for example, routine wisdom teeth extraction).

Do not bill CPT 41874 for indications not meeting the policy criteria; such claims risk denial as not medically necessary.

Clinical Background

Alveoloplasty is the surgical recontouring of the maxillary and/or mandibular alveolar ridge to obtain optimal tissue support for prosthetic appliances and to remove sharp bony prominences or undercuts. The procedure involves mucosal incisions to expose alveolar bone and contouring of bone with instruments (drills/osteotomes/files) followed by suturing of the mucosa over the contoured bone. Alveoloplasty is typically performed to prepare the oral tissues for prosthetic rehabilitation, to facilitate implant placement considerations, or to address pathology while aiming to preserve bone and soft tissue.

Key Terms and Code Definitions

Alveoloplasty (CPT 41874) — definition and procedure description (inv-20)

DefinitionAlveoloplasty is the surgical recontouring of the alveolar ridge to remove sharp areas or undercuts of alveolar bone, often performed in preparation for a prosthesis or other dental restoration.

Procedure stepsThe physician makes mucosal incisions over the alveolus, exposes alveolar bone, and uses drills, osteotomes, or files to contour the bone; the mucosa is then sutured over the contoured bone.

PurposeAims to create a smooth bone surface to improve prosthesis seating, remove bony protuberances, and optimize tissue support for restorations.

Alveoloplasty — CPT listing and clinical context (inv-21)

CPT code41874 — Alveoloplasty, each quadrant (specify).

Policy listingCPT 41874 is listed as considered medically necessary when the applicable policy criteria are met.

Clinical referencesPolicy provides clinical context and references to support indications and technique (see References section).