ModifiedColorado Rocky Mountain Health PlansPolicy DCP027.14

Oral Surgery: Miscellaneous Surgical Procedures

Clinical coverage guidance for selected oral and maxillofacial surgical procedures for UnitedHealthcare Dental members; describes indications, contraindications, definitions, applicable CDT codes, and supporting clinical guidance that affect dental providers performing these procedures.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyOral Surgery: Miscellaneous Surgical Procedures

Policy CodePolicy DCP027.14

Change TypeCode list updatedreferences refreshed

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionVerify member-specific benefits and prior authorization requirements using the member's Certificate of Coverage before providing services.

SourceLink

POLICY UPDATE CHANGES

Removed CPT codes 21210, 21215, 30580, 41899, and 42699 from Applicable Codes.

Updated References section to reflect the most current information.

Removed CPT codes 21210, 21215, 30580, 41899, and 42699

10+CDT procedure codes listed

≥2 mmsinus perforation threshold

60 minextraoral time limit

5CPT codes removed

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Coverage Criteria

Oroantral Fistula Closure

Covered when ALL of the following are met

Oroantral fistula closure indication: Oroantral fistula will not heal spontaneously and must be surgically repaired.

Primary Closure of a Sinus Perforation

Covered when ALL of the following are met

Sinus perforation closure indication: Primary closure is indicated for large (≥ 2mm) defects resulting from routine tooth extraction, retrieval of root tips, or implant placement.≥ 2mm

Tooth Reimplantation/Repositioning

Indications and contraindications are specified

Indications: Subluxation injuries to permanent teeth; lateral luxation injuries of primary and permanent teeth; extrusion injuries of < 3 mm in an immature developing primary tooth; avulsion of permanent teeth.

Contraindications (when reimplantation not indicated): Primary teeth if injury is severe or tooth is near exfoliation; intrusion injuries to primary teeth when the apex is displaced toward the permanent tooth germ; extrusion injuries of a primary tooth that is fully formed, mobile, and near exfoliation, or the child is unable to cope with an emergency situation; when a tooth has been out of the oral cavity for 60 minutes or more; lack of alveolar integrity; risk of ankylosis; in these situations extraction is recommended.60 minutes

Surgical Repositioning of Teeth

Indications: Treatment of displacement injuries to permanent teeth; extrusion of teeth with crown/root fractures to prepare for restoration of permanent teeth.

Sinus Augmentation Procedures

Covered when clinically indicated to enable implant placement in cases of inadequate bone; not indicated when sinus ventilation/clearance is blocked.

Indications: When there is poor bone quality or quantity that would contraindicate implant placement.

Contraindications: Not indicated when conditions blocking the ventilation and clearance of the maxillary sinus are present.

Raghoebar et al. (2019) systematic review reports high implant survival after MSFA but notes variable healing periods and suggests prolonged healing when certain graft materials are used.

Salivary Gland and Duct Procedures

Included procedures: Removal of sialoliths; surgical excision of portions of, or the entire, salivary gland; repair of salivary fistulas and defects of salivary ducts; procedures may be performed intraorally or extraorally.

Contraindications: Procedures may not be indicated for individuals with unmanaged medical conditions (including but not limited to metabolic, cardiovascular, autoimmune/inflammatory, or genetic conditions affecting collagen synthesis) or for individuals taking medications that negatively affect healing (including but not limited to immunosuppressive agents, corticosteroids, anticoagulants, NSAIDs, and nicotine).

For tooth reimplantation and stabilization of an accidentally evulsed or displaced tooth, extraction is recommended in specified primary tooth scenarios and other situations where reimplantation is not appropriate. Examples include: primary teeth with severe injury or those near natural exfoliation; intrusion injuries to primary teeth when the apex is displaced toward the permanent tooth germ; extrusion injuries of a primary tooth that is fully formed, mobile, near exfoliation, or when the child cannot tolerate emergency care; lack of alveolar integrity; and cases with substantial risk of ankylosis. Additionally, reimplantation is not indicated when the tooth has been out of the oral cavity for 60 minutes or more.

Sinus augmentation is intended to enable implant placement when residual maxillary bone quality or quantity is inadequate. However, sinus augmentation is not indicated when conditions blocking the ventilation and clearance of the maxillary sinus are present; such conditions may prevent appropriate healing and graft integration and therefore contraindicate the procedure.

Coverage determinations using this policy must be made in the context of the member's specific benefit plan. The member's Certificate of Coverage or plan document governs when terms differ from this standard policy, and applicable federal or state mandates should be checked as they may override policy provisions.

Certain procedures may not be appropriate for individuals with unmanaged medical conditions or for those taking medications that impair healing. Examples of such conditions include metabolic, cardiovascular, autoimmune/inflammatory disorders, and genetic conditions affecting collagen synthesis. Medications and exposures that can negatively affect healing include, but are not limited to, immunosuppressive agents, corticosteroids, anticoagulants, NSAIDs, and nicotine. When these factors are present and uncontrolled, the procedure should be deferred until the condition or risk factor is managed.

Coding

Applicable CDT procedure codesCPT | mixed

D7260	Oroantral fistula closure
D7261	Primary closure of a sinus perforation
D7270	Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7272	Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)
D7290	Surgical repositioning of teeth
D7295	Harvest of bone for use in autogenous grafting procedure
D7951	Sinus augmentation with bone or bone substitutes via a lateral open approach
D7952	Sinus augmentation via a vertical approach
D7979	Surgical sialolithotomy
D7980	Surgical sialolithotomy

1–10 of 14

1/2

Removed CPT CodesCPTNot Covered

21210	CPT code removed
21215	CPT code removed
30580	CPT code removed
41899	CPT code removed
42699	CPT code removed

Sinus perforation size

Sinus perforation size threshold≥ 2 mm

ContextIndicated for primary closure when defect results from routine tooth extraction, retrieval of root tips, or implant placement

Source guidancePolicy states 'Primary closure... is indicated for large (≥ 2mm) defects'

Maximum extraoral time for reimplantation

Maximum extraoral time< 60 minutes (reimplantation not indicated when tooth has been out of the oral cavity for 60 minutes or more)

Related contraindicationsReimplantation not indicated when lack of alveolar integrity or risk of ankylosis present

Provider Actions and Requirements

Prior Authorization

Verify Benefits / Prior Authorization

Providers should verify member-specific benefits and prior authorization requirements before scheduling or performing services. Use the member's Certificate of Coverage or benefit plan document to confirm whether the service is covered and whether prior authorization is required.

Verify prior authorization requirements with the member's plan before rendering services.
Confirm any plan-specific coverage limits, medical benefit vs dental benefit determinations, and applicability of state or federal mandates.

Documentation Required

Check Member-Specific Documents

Providers must check the member-specific benefit plan document and applicable federal or state mandates before using this policy. In the event of a conflict, the member's benefit plan document governs coverage determination.

Reference the Certificate of Coverage or health plan documentation for specific coverage guidelines.

Background

This policy addresses selected oral and maxillofacial surgical procedures used to treat conditions related to infection, acute trauma, complications of tooth extraction (including oroantral communications), effects of radiation therapy, and congenital or acquired defects that affect oral function and form. Some procedures described may be medical in nature depending on the clinical scenario and the member's plan; providers should confirm whether a procedure is covered under dental or medical benefits per the member's plan documentation.

Sinus augmentation is discussed here as a technique to augment the maxillary sinus floor and place graft material when native bone is insufficient for implant placement. Other included procedures cover closure of oroantral fistulae, primary closure of sinus perforations, tooth reimplantation/repositioning and stabilization, surgical repositioning of displaced teeth, and salivary gland and duct procedures such as sialolith removal and gland excision.

Definitions

Oroantral Fistula

DefinitionAn open connection between the maxillary sinus usually caused by extraction of maxillary posterior teeth.

Typical causeMost commonly follows extraction of maxillary posterior teeth

Clinical relevanceMay require surgical repair when not expected to heal spontaneously

Avulsion

DefinitionComplete displacement of the tooth out of socket; the periodontal ligament is severed, and fracture of the alveolus may occur.

Acronym/Source(AAPD)

Clinical implication

Revision History & Policy Changes

2025-08-01codes_removedLatest

Removed CPT codes 21210, 21215, 30580, 41899, and 42699 from the list of applicable codes.

2025-08-01references_updated

Updated References section to reflect the most current information.

2025-08-01prior_version_archived