CurrentColorado Rocky Mountain Health PlansPolicy DCP022.13

Non-Surgical Extractions

Defines indications, description, and coding reference for non-surgical extractions of erupted teeth for dental plan coverage decisions; intended for providers and adjudicators of Colorado Rocky Mountain Health Plans dental benefits.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyNon-Surgical Extractions

Policy CodePolicy DCP022.13

Change TypeNo material change

Effective DateJan 1, 2026

Next Review Date

Key ActionVerify coverage and prior authorization for listed CDT codes against the member specific benefit plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2procedure codes listed

8clinical indications

1service description

updatedreferences updated

Coverage Criteria for Non-surgical Extractions

Indications for Non-surgical Extractions

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Coverage of non-surgical dental extractions is subject to the member's specific benefit plan and applicable laws. Listing of a code in this guideline does not imply that the service described by the code is a covered or noncovered health service, and the inclusion of a code does not guarantee reimbursement or claim payment. Services not covered by the member specific benefit plan or excluded by law are not covered. Before providing services, verify benefits and any prior authorization requirements against the member specific benefit plan; in the event of a conflict, the member specific benefit plan document governs.

Provider Actions and Verification

Prior Authorization

Verify coverage and prior authorization

Coverage for listed CDT codes should be verified against the member-specific benefit plan; prior authorization requirements depend on that plan. Listing of a code does not imply coverage — benefit determination is made by the member-specific plan document and applicable laws or mandates. In case of any conflict between this policy and the member-specific benefit plan, the member-specific plan governs. Verify eligibility, coverage limits, and prior authorization with the payer before providing services.

Verify member eligibility and benefits prior to service.
Confirm whether prior authorization is required by the member-specific plan.
Listing of a code is for reference only and does not guarantee reimbursement.

Note

Nonpharmacologic pain management

Encourage nonpharmacologic pain management strategies where appropriate per CA AB2585.

Documentation Required

Member-specific benefit verification

Reference the member-specific benefit plan and any applicable federal or state mandates when determining coverage. If the member-specific benefit plan language conflicts with this policy, the member-specific plan controls. Check for plan-specific limits, exclusions, and required documentation; resolve disputes per the member’s plan grievance/appeal procedures.

Confirm plan-specific coverage, limitations, and exclusions.
Follow member-specific plan grievance/appeal process for coverage disputes.
Ensure documentation meets plan requirements to support medical necessity and claims processing.

Billing Rule

Coverage depends on member benefit

Listing of CDT codes in this document is for reference only and does not imply that the service is a covered benefit. Benefit coverage depends on the member-specific plan document and applicable laws; inclusion here does not guarantee reimbursement or a right to payment.

D7111 — Extraction, coronal remnants - primary tooth.
D7140 — Extraction, erupted tooth or exposed root (elevation and/or forceps removal).

Background

Non-surgical extractions are procedures to remove erupted teeth using instruments such as elevators and forceps to separate the periodontium and extract the tooth. The procedure may include smoothing the socket and placing sutures when indicated. Typical clinical indications include non-restorable teeth, failed endodontics, teeth with a poor prognosis, supernumerary or crowding/nonfunctional teeth, orthodontic considerations, primary teeth interfering with eruption of permanent teeth, and teeth that interfere with planned prosthodontic treatment. Each listed indication alone may justify a non-surgical extraction when documented.

OpenPayer

Non-Surgical Extractions

Coverage Criteria for Non-surgical Extractions

Applicable Codes (CDT)

Provider Actions and Verification

Background

Definitions

D7111	Extraction, coronal remnants - primary tooth.
D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)