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    v1.0.31
    OpenPayerPolicy UpdatesDental/Oral & MaxillofacialDelta Dental Ohio Extraction Coverage | OpenPayer
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    CurrentDelta Dental of OhioPolicy 282.24.v2

    Clinical Criteria for Extraction of Teeth

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    This policy establishes clinical and documentation criteria Delta Dental of Ohio uses to evaluate the medical necessity and clinical appropriateness of tooth extraction procedures when benefit payment requires utilization management review. It applies to dental providers submitting extraction claims or prior authorization requests under applicable member dental plans.

    Policy Summary
    PayerDelta Dental of Ohio
    PolicyClinical Criteria for Extraction of Teeth
    Policy CodePolicy 282.24.v2
    Change TypeNo material change
    Effective DateJun 21, 2025
    Next Review DateNot specified
    Key ActionSubmit appropriate radiographs and a medical-necessity narrative when prior authorization is required.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    8Applicable extraction procedure codes
    4Third-molar teeth exempt from prior authorization
    Entire toothRequired radiographic coverage
    Each toothPathology or documented need required

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    3
    Impaction classifications defined

    Tooth Extraction Medical Necessity Criteria

    Conditions precluding tooth restoration and maintenance

    Tooth extraction is generally indicated when ALL of the following apply: the condition is documented, the tooth cannot reasonably be maintained in function, and extraction is clinically appropriate under the patient's circumstances.

    Generally indicated extraction

    • Required circumstances

      • Conditions precluding restoration and maintenance

        • Qualifying conditions: Unrestorable structural deterioration from dental caries or restoration failure; untreatable developmental anomaly; untreatable coronal or root fracture; or untreatable internal or external tooth resorption.

    Conditions that may require tooth extraction for management

    Extraction may be indicated when ANY of the following conditions is documented.

    Conditions requiring extraction for management: Pulpal or periapical lesion; advanced periodontal disease; acute or chronic infection; ongoing pain where conservative treatment is documented as ineffective; traumatic injury to teeth and/or face; associated pathologic lesion; an ectopic position that may cause damage to other teeth, including supraeruption or traumatic occlusion; or interference with eruption of an adjacent tooth.

    Other conditions where extraction may be indicated

    Extraction may be indicated when ANY of the following applies.

    Additional accepted indications: An impacted tooth other than a third molar cannot erupt into a functional position and presents with a generally accepted indication for removal; an impacted third molar with incomplete root development is not expected to erupt by the middle of the third decade and presents with a generally accepted indication for removal; a nonbeneficial supernumerary tooth is present; or extraction is required for orthognathic or rehabilitative surgery, orthodontic treatment, prosthodontic rehabilitation, or prevention of a medical condition or medical treatment.

    For patients outside these published criteria, relevant clinician documentation explaining the necessity of extraction may be considered.

    General extraction guidelines

    General extraction guidelines require ALL applicable conditions below.

    General extraction requirements: The tooth cannot be saved because it is broken down, poorly supported by the alveolar bone, or affected by a pathological condition; an impacted tooth is removed only when impaction makes removal necessary; and prophylactic removal of an asymptomatic tooth or a tooth without overt clinical pathology is covered only when at least one tooth is symptomatic.

    Extractions that would render the patient edentulous must be deferred until prior authorization to construct a denture has been given, except in an absolute emergency supported by documentation.

    Procedure-code-specific extraction criteria

    Code-specific coverage requires ALL elements applicable to the submitted code.

    Procedure-code clinical support

    • Applicable submitted-code criterion

      • D7210: The involved tooth was erupted and requires bone relief (alveoloplasty) and/or tooth sectioning for removal.
      • D7220: The involved tooth has a soft-tissue impaction requiring incision and mucoperiosteal flap elevation for tooth removal.
      • D7230 or D7240: The involved tooth has a partial or complete bony impaction requiring mucoperiosteal flap elevation and bone relief (alveoloplasty) for tooth removal.

    Code-specific billing requirements

    The procedure must also comply with ALL applicable billing and clinical requirements.

    Code use and billing requirements

    • D7140: Bill once per tooth and do not bill in combination with another extraction or root recovery code for that tooth.
    • D7210: Do not bill with any other extraction or root recovery code for the same tooth.
    • Submitted code: The submitted extraction code accurately represents the documented procedure and clinical circumstances.

    Surgical removal of erupted tooth

    D7210 is covered when ALL of the following procedure characteristics are present.

    D7210 surgical removal of erupted tooth: The tooth is erupted and requires elevation of a mucoperiosteal flap and removal of bone and/or sectioning of the tooth.

    Related cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone, and closure are included.

    Soft-tissue impaction

    D7220 applies when ALL of the following clinical characteristics are present.

    D7220 soft-tissue impaction: The tooth requires incision of overlying soft tissue and removal of the tooth without removal of bone.

    Partial eruption does not disqualify the tooth when soft tissue covers part of the occlusal surface, including in a distoangular position.

    Partial bony impaction

    D7230 applies when ALL of the following clinical characteristics are present.

    D7230 partial bony impaction: The crown is partially covered by bone, and removal requires incision of overlying soft tissue, elevation of a flap, removal of bone, and removal of the tooth.

    Partial eruption does not disqualify the classification when bone covers the greatest convexity of the distal portion of the crown. A radiograph of the impaction must be maintained in the clinical record.

    Complete bony impaction

    D7240 applies when ALL of the following clinical characteristics are present.

    D7240 complete bony impaction

    • Impaction characteristics: The crown is completely covered by bone, or a substantial part of the tooth above the greatest convexity of the crown is covered by bone on both the mesial and distal sides, as demonstrated radiographically.
    • Required removal technique: Removal requires incision of overlying soft tissue, elevation of a flap, removal of bone, and tooth sectioning if necessary.

    Complete bony impaction with unusual surgical complications

    D7241 applies when ALL of the following criteria are met.

    D7241 complete bony impaction with unusual surgical complications

    • Clinical circumstances: The tooth has a complete bony impaction with unusual surgical complications, such as difficult access, a requirement for nerve dissection, or a need for sinus closure.
    • Prior authorization and imaging: Prior authorization is obtained, and the full-mouth radiographic series or panoramic film is submitted with the request for review.

    Residual tooth root after incomplete prior extraction

    D7250 authorization is limited to residual roots caused by an incomplete prior extraction and requires ALL of the following.

    D7250 authorization criteria

    • Residual-root circumstances: Residual tooth-root remnants remain because of an incomplete prior extraction, and the root structure is encased in bone to a degree requiring soft-tissue incision and bone relief (alveoloplasty) for removal.
    • Separate procedure and provider eligibility: The treatment is performed separately from the previous incomplete extraction, and the requesting provider or dental group was not the provider or dental group reimbursed for the original extraction.
    • Prior authorization and imaging: Prior authorization is obtained, and a full-mouth radiographic series or panoramic film is submitted with the request for review.

    Extraction of a functional erupted tooth is not covered when there is no generally accepted indication for removal.

    Extraction for eruption pain and inflammation is not covered when the tooth is expected to erupt into a functional position.

    Removal of an unerupted non-third molar is not covered when the tooth is expected to erupt into a functional position.

    Removal of an unerupted third molar is not covered when the tooth is expected to erupt into a functional position by the middle of the third decade.

    Removal is not covered for a fully bone-covered impacted third molar with completed root formation in a patient beyond the third decade when there is no generally accepted indication for removal. Monitoring for changes in position or development of disease is recommended.

    An optional extraction may not be covered when the patient is at risk because of antiresorptive agent therapy or head and neck radiotherapy.

    Extraction may not be covered when a more conservative treatment can manage the condition and make extraction unnecessary.

    Extraction of a primary tooth is not covered when exfoliation is imminent.

    Authorization for D7250 is not granted for residual root remnants caused by decay or trauma.

    Authorization for D7250 is not granted to the same provider or dental group that was reimbursed for the original extraction.

    Extraction may be considered not medically necessary or clinically inappropriate when there is no generally accepted indication, conservative treatment is sufficient, or the patient's systemic status makes extraction a serious health risk.

    An incomplete or improperly performed extraction may be considered deficient in clinical quality, including incomplete removal; damage to adjacent teeth, tissues, restorations, or neurovascular structures; displacement into the maxillary sinus, throat, or another anatomic space; fracture of the maxilla or mandible; or injury to the temporomandibular joint.

    Impaction or symptoms alone may not establish medical necessity. Documentation must demonstrate diagnosed pathology or another specific need for removal, and each extracted tooth must have supporting evidence.

    Applicable Procedure Codes and Coding Rules

    Applicable CDT Extraction Procedure CodesCPT
    D7111extraction, coronal remnants - primary tooth
    D7140extraction, erupted tooth or exposed root (elevation and/or forceps removal)
    D7210extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated
    D7220removal of impacted tooth - soft tissue
    D7230removal of impacted tooth - partially bony
    D7240removal of impacted tooth - completely bony
    D7241removal of impacted tooth - completely bony, with unusual surgical complications
    D7250removal of residual tooth roots (cutting procedure)
    Surgical extraction, impacted-tooth removal, and residual-root removal codesCPT
    D7210Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth
    D7220Removal of impacted tooth - soft tissue
    D7230Removal of impacted tooth - partially bony teeth
    D7240Removal of impacted tooth - complete bony
    D7241Removal of impacted tooth - complete bony with unusual surgical complications
    D7250Surgical removal of a residual tooth root (cutting procedure)
    Third-molar prior authorization exemption
    Exempt third molarsTeeth 1, 16, 17, and 32
    Applicable proceduresD7220, D7230, and D7240
    Other teethRemoval of all other teeth using D7220, D7230, or D7240 requires prior authorization
    Horizontally impacted lower third molar criterion
    Tooth typeHorizontally impacted lower third molar
    ClassificationComplete bony impaction
    Crown-groove requirement

    Authorization, Documentation, and Billing Requirements

    Documentation Required

    Submit Authorization Documentation

    When prior authorization is required, submit appropriate radiographs clearly showing the adjacent and opposing teeth, along with documentation supporting the request.

    • Submit bitewings, periapicals, or a panorex as applicable.
    • Include a narrative demonstrating medical necessity and evidence of diagnosed pathology or demonstrable need.
    Prior Authorization

    D7220 Authorization by Tooth

    D7220 does not require prior authorization for third molars, but authorization is required when the code is used for any other tooth.

    • Third-molar teeth: 1, 16, 17, and 32 — no prior authorization required.
    • All other teeth billed under D7220 — prior authorization required by tooth.

    Policy Background

    Tooth extraction is considered when a tooth cannot reasonably be maintained in function because of conditions such as non-restorable caries or fracture, endodontic or periodontal disease, infection, trauma, pathologic lesions, ectopic position, or treatment requirements. The clinical approach depends on whether the tooth is erupted or impacted and on the surgical measures needed for removal.

    Extraction and Impaction Definitions

    Soft-tissue impaction
    DefinitionAn impacted tooth requiring an incision of overlying soft tissue and removal without removing bone
    Partial eruptionPartial eruption does not disqualify the tooth from soft-tissue impaction classification
    Occlusal-surface coverageSoft tissue must cover part of the occlusal surface
    Surgical removal of erupted tooth
    Tooth statusThe tooth is erupted
    Required surgical approachRemoval requires bone relief (alveoloplasty) and/or tooth sectioning
    Flap elevation
    Policy Summary
    PayerDelta Dental of Ohio
    PolicyClinical Criteria for Extraction of Teeth
    Policy CodePolicy 282.24.v2
    Change TypeNo material change
    Effective DateJun 21, 2025
    Next Review DateNot specified
    Key ActionSubmit appropriate radiographs and a medical-necessity narrative when prior authorization is required.
    SourceLink
    On This Page
    Tooth Extraction Medical Necessity CriteriaApplicable Procedure Codes and Coding RulesAuthorization, Documentation, and Billing RequirementsPolicy BackgroundExtraction and Impaction Definitions
    D7241:
    The involved tooth has a complete bony impaction with unusual surgical complications, such as difficult access, nerve dissection, or sinus closure.
  1. D7250: The residual tooth-root procedure is performed separately from a previous incomplete extraction, and the root structure is encased in bone to a degree requiring soft-tissue incision and bone relief (alveoloplasty) for removal.
    2. The central groove of the crown must not be above the occlusal plane
    Prior Authorization

    Authorize Denture Treatment Before Edentulous Extraction

    Extractions that would render a patient edentulous must be deferred until prior authorization to construct a denture has been granted, except in an absolute emergency.

    • Obtain denture authorization before performing the extractions.
    • For an absolute emergency, submit documentation supporting the emergency removal.
    Prior Authorization

    D7220 Authorization by Tooth Type

    Use D7220 only when the tooth has a soft-tissue impaction requiring incision of overlying soft tissue and removal without bone removal. Prior authorization depends on the tooth type.

    • Third molars — teeth 1, 16, 17, and 32 — do not require prior authorization.
    • All other teeth billed under D7220 require prior authorization.
    Prior Authorization

    D7230 Authorization by Tooth Type

    Use D7230 only for a partially bony impacted tooth requiring flap elevation, bone removal, and tooth removal. Prior authorization is determined by tooth type.

    • Third molars — teeth 1, 16, 17, and 32 — do not require prior authorization.
    • All other teeth billed under D7230 require prior authorization.
    Prior Authorization

    D7240 Authorization by Tooth Type

    Use D7240 only for a completely bony impacted tooth requiring flap elevation, bone removal, and, if necessary, sectioning. Prior authorization is determined by tooth type.

    • Third molars — teeth 1, 16, 17, and 32 — do not require prior authorization.
    • All other teeth billed under D7240 require prior authorization.
    Prior Authorization

    D7241 Always Requires Prior Authorization

    Prior authorization is required for every D7241 procedure involving removal of a complete bony impaction with unusual surgical complications.

    • Examples include difficult access, nerve dissection, or sinus closure.
    Prior Authorization

    D7250 Always Requires Prior Authorization

    Prior authorization is required for every D7250 surgical removal of a residual tooth root.

    • Authorization is limited to remnants remaining after an incomplete prior extraction.
    Documentation Required

    Submit Complete Preoperative Radiographs

    Submit diagnostic-quality preoperative radiographs covering both the teeth to be extracted and the opposing dentition. Images must permit evaluation of each tooth from crown to root tip.

    • Use radiographs appropriate to the case, including bitewings, periapicals, or a panorex.
    • Ensure the relevant dentition and opposing teeth are clearly visualized.
    Documentation Required

    Explain Medical Necessity When Imaging Is Inconclusive

    If radiographs do not clearly establish that extraction is medically necessary, submit record-consistent documentation explaining the preoperative rationale for treatment planning the extraction.

    • Include a medical-necessity narrative addressing the clinical findings and treatment rationale.

    Unsupported block type: documentation

    Documentation Required

    Evaluate Pediatric Extractions

    Before extracting a pediatric tooth, perform and document a thorough age-appropriate medical, clinical, and radiographic evaluation.

    • Assess crown and root development, the relationship of primary roots to permanent successors, adjacent-tooth positioning, and future occlusion.
    • Communicate evaluation concerns with the parent or legal guardian during informed consent.
    Documentation Required

    Document Emergency Extractions

    For emergency extractions performed when advance authorization was not possible, submit documentation supporting the absolute emergency and include appropriate radiographs with the claim.

    • Radiographs must clearly show the adjacent and opposing teeth.
    • Explain why prior authorization could not be obtained.
    Note

    Address Individual Patient Circumstances

    Coverage determinations may consider individual patient characteristics and circumstances, including age, comorbidities, complications, treatment progress, psychosocial situation, and home environment.

    • Also consider available services in the local dental delivery system and their ability to meet the patient's needs.
    Documentation Required

    Maintain Impaction Radiographs

    Maintain a radiograph of each D7230 or D7240 impaction in the patient's clinical record.

    • The image should support the documented classification as partial or complete bony impaction.
    Prior Authorization

    Include Imaging With D7241 Requests

    Submit a radiograph of the impaction with every D7241 prior authorization request.

    • Submit the full-mouth radiographic series or a panoramic film for review.
    Prior Authorization

    Include Imaging With D7250 Requests

    Submit radiographic documentation with every D7250 prior authorization request.

    • Submit a full-mouth radiographic series or panoramic film for review.

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Denial Risk

    Do Not Rely on Symptoms or Impaction Alone

    Symptoms or impaction alone may not establish coverage. Document diagnosed pathology or another demonstrable need for each tooth rather than relying on anticipated future pathology.

    • Examples of demonstrable need include non-restorable decay, recurrent pericoronitis, a tooth erupting at an angle and impinging on second molars, a dentigerous cyst or other growth, root resorption, or an over-erupted third molar lacking opposing contact.
    • Review may consider all submitted documentation, but each tooth must show supporting pathology or need.
    Billing Rule

    Do Not Unbundle D7210

    Do not unbundle extraction services for the same tooth when billing D7210.

    • D7210 cannot be billed with another extraction or root-recovery code for the same tooth.
    Prior Authorization

    Authorize Non-Third-Molar Impactions

    Non-third-molar impactions billed under D7230 or D7240 require prior authorization.

    • Third molars — teeth 1, 16, 17, and 32 — do not require prior authorization under these codes.
    • All other teeth require authorization by tooth.
    Prior Authorization

    Authorize and Image Unusual D7241 Complications

    D7241 requires prior authorization and radiographic support because it is reserved for complete bony impactions with unusual surgical complications.

    • Submit the full-mouth series or panoramic film with the request.
    • Document unusual complications such as difficult access, nerve dissection, or sinus closure.
    Billing Rule

    Apply D7250 Residual-Root Restrictions

    D7250 authorization is limited to residual roots left after an incomplete prior extraction and is not available for roots remaining because of decay or trauma.

    • Submit a full-mouth radiographic series or panoramic film with the request.
    • Authorization will not be granted to the same provider or dental group that was reimbursed for the original extraction.
    Mucoperiosteal flap elevation is included if indicated
    Bony impaction
    DefinitionAn impacted tooth with a crown partially or completely covered by bone
    Required accessRemoval requires mucoperiosteal flap elevation
    Bone removalBone relief is required for removal
    Unusual surgical complication
    Tooth statusThe tooth is completely bony impacted
    Unusual access or techniqueThe procedure may require difficult access or nerve dissection
    Sinus involvementSinus closure is an example of an unusual surgical technique
    Soft-tissue impaction and removal method
    Removal methodRemoval requires incision of overlying soft tissue without the necessity of removing bone
    Impaction statusThe tooth is impacted
    Partial eruptionPartial eruption does not disqualify the classification when soft tissue covers part of the occlusal surface
    Partial bony impaction
    Crown coverageThe crown is partially covered by bone
    Required surgical stepsRemoval requires incision of overlying soft tissue, flap elevation, bone removal, and tooth removal
    Partial eruptionPartial eruption does not disqualify the classification when bone covers the greatest convexity of the distal crown
    Complete bony impaction
    Complete coverageThe crown is completely covered by bone
    Alternative radiographic findingA substantial part of the tooth above the greatest convexity is covered by bone on both the mesial and distal sides
    DocumentationThe classification must be demonstrated radiographically
    Horizontally impacted lower third molar criterion
    Tooth typeHorizontally impacted lower third molar
    ClassificationComplete bony impaction
    Required positionThe central groove of the crown must not be above the occlusal plane