RetiredEmpire BluecrossPolicy 07-201

Removal of Third Molar Teeth

Clinical policy governing when extraction (including surgical and coronectomy) of third molar teeth is considered medically/dentally necessary for Empire Bluecross members; applies to dental providers requesting benefit determination under the plan.

Policy Summary

PayerEmpire Bluecross

PolicyRemoval of Third Molar Teeth

Policy CodePolicy 07-201

Change TypeArchived

Effective DateJan 1, 2022

Next Review Date

Key ActionSubmit appropriate diagnostic periapical or panoramic images and operative documentation when requesting prior authorization or clinical review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

D7140–D7251Procedure codes listed

01/01/2022Policy publish date

11/11/2022Policy archived date

Clinical indications listNamed indications

Coverage Criteria for Third Molar Extraction

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Primary indications: Tooth presents with pain, dental caries, periodontal disease, periapical pathology, split/cracked tooth, tooth mobility, internal or external root resorption, infection, severe anomaly of the crown or root precluding prosthetic or restorative treatment, traumatic injury, loss of pulp vitality secondary to infection, ectopic position causing damage to other teeth, tooth in the line of fracture, or prophylactic removal required because of organ transplant, chemotherapy, radiation therapy, prosthetic heart valve replacement, joint replacement, or orthodontic necessity.

Each tooth must have documented symptom or pathology; impacted teeth are not pathologic by definition unless associated pathology is present.

Imaging and documentation: Appropriate diagnostic periapical or panoramic images are provided for the extraction. When billing a surgical extraction, submitted documentation (e.g., complete operative report, intraoral photos, clinical narrative) must demonstrate the surgical elements (soft tissue incision, flap reflection, removal of soft and/or osseous tissue as applicable, complete removal of tooth and roots, and closure).

Missing or insufficient documentation may result in denial or recoding of the procedure billed.

Surgical designation and special considerations: An erupted third molar does not automatically qualify as a surgical extraction; surgical designation requires documented need for surgical techniques as defined (incision, flap, bone removal). Special surgical considerations (e.g., intimate involvement with mandibular canal or adjacent roots, ramus obstruction, unusual angulation, proximity to maxillary sinus) require supporting clinical notes and narrative.

Without documentation of surgical elements, a surgical extraction code may not be supported.

Coronectomy (D7251) is appropriate when imaging documents moderate-to-high risk to the inferior alveolar nerve; cone beam CT may supplement panoramic imaging when indicated.

Coronectomy is an accepted procedure when imaging demonstrates high nerve injury risk and should be justified in submitted imaging and operative documentation.

Removal of third molar teeth for patient or dentist convenience or for cosmetic reasons is not a benefited service under the plan. The plan requires that extractions meet contractual and clinical standards before benefits are provided; absence of an accepted clinical indication means the service is not considered a covered benefit.

When an extraction is performed in conjunction with or in preparation for a non-covered or denied service, related services may also be not covered or denied; the plan evaluates benefit determination against the member's contract and accepted standards of dental care.

Teeth that do not present with one of the listed clinical indications are contractually not benefited. If a requested extraction lacks documentation of an accepted indication (for example pain, caries, periodontal or periapical pathology, infection, trauma, or other listed pathology), the claim may be denied.

Services performed in conjunction with or in preparation for a non-covered or denied service are also subject to denial; providers should ensure the tooth meets an accepted indication and submit supporting clinical documentation when requesting benefit determination.

Procedure Codes

CDT codes listedCDT

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
D7251	Coronectomy intentional partial tooth removal

Provider Requirements and Documentation

Documentation Required

Documentation required for review

Prior authorization/clinical review requires submission of appropriate diagnostic imaging and operative documentation to justify the procedure. Appropriate diagnostic periapical or panoramic images must be provided for all extractions. When a surgical extraction is billed, documentation supporting the procedural code (for example: a complete operative report, intraoral photos, or cone beam CT when indicated) is required.

Appropriate diagnostic periapical or panoramic images required for all extractions
When surgical extraction is billed, submit complete operative report and intraoral photos; CBCT may be required for nerve proximity concerns

Note

Provider responsibilities

Providers must ensure all required documentation is submitted with prior authorization or clinical review requests. Failure to submit adequate diagnostic images and operative notes may result in delay or denial of benefits.

Submit diagnostic images with initial request
Include operative report when surgical techniques (flap, bone removal, root removal) are performed

Denial Risk

Removal not benefited if the teeth do not present with an accepted clinical indication

Extraction of teeth that do not meet accepted clinical indications is not a covered benefit. Removal is not benefited if the tooth or teeth do not present with an accepted indication (symptomatic or pathologic condition), or when the extraction is for patient or dentist convenience or for cosmetic reasons. Documentation must demonstrate pathology or symptoms for each tooth; some plans require symptoms/pathology for bone-impacted third molars specifically.

Removal not benefited if no accepted clinical indication documented
Cosmetic or convenience extractions are not covered
Detail symptoms or pathology for each individual tooth; some plans allow removal of opposing asymptomatic third molar only when the corresponding tooth is symptomatic/pathologic

Documentation Required

Required documentation and imaging

When coding and billing for extractions, providers should document the type of impaction (soft tissue, partial bone, complete bone) and any special considerations (e.g., intimate root relationship with mandibular canal, proximity to maxillary sinus, unusual angulation). Erupted third molars are not automatically surgical extractions; surgical designation requires soft tissue incision, flap reflection, removal of soft and/or osseous tissue, complete removal of tooth and roots, and closure of the surgical site.

Document impaction type and clinical rationale for surgical approach
Coronectomy may be appropriate for high inferior alveolar nerve risk (documented by panoramic or CBCT)

Background and Indications

Indications for tooth extraction include, but are not limited to: pain; dental caries; periodontal disease; periapical pathology; split or cracked tooth; tooth mobility; internal or external root resorption; infection; severe crown or root anomaly preventing restoration; traumatic injury; loss of pulp vitality secondary to infection; ectopic position causing damage to other teeth; tooth in the line of a fracture; and prophylactic removal required for certain medical therapies (for example organ transplant, chemotherapy, radiation therapy, prosthetic heart valve or joint replacement).

Impacted teeth are not considered pathologic solely by virtue of impaction; an impacted tooth must have associated pathology or a listed indication to be considered for benefit. Coronectomy is an accepted option when imaging documents a moderate-to-high risk to the inferior alveolar nerve.

Definitions

inv-10: Surgical extraction

DefinitionSurgical extraction requires a soft tissue incision, flap reflection, removal of soft and/or osseous (bone) tissue, complete removal of the tooth and roots, and closure of the surgical site.

When surgical designation appliesAn extraction of a fully erupted tooth may be considered surgical if tooth position or root formation dictates surgical removal.

Documentation requirementIf surgical extraction is not evident from submitted clinical information, a complete operative report or equivalent documentation is required to support the billed surgical code.

inv-11: Impacted tooth

DefinitionA tooth that cannot fully erupt into function due to an abnormal position or impingement of other anatomic structures; not considered pathologic unless associated pathology is present.

Clinical implicationImpacted status alone does not constitute pathology; documentation of associated pathology is required to support extraction for pathologic indications.

Relation to codingImpaction classification (soft tissue, partial bone, complete bone) guides selection of the appropriate impacted-tooth removal code.

inv-12: Soft tissue impaction

DefinitionSoft tissue impaction: the tooth crown is partially or completely covered by soft tissue and is generally located below the level of occlusion.

Clinical noteWhen a soft tissue extraction is not evident from submitted documentation, a complete operative report or intraoral photos may be required to support the code billed.

Coding implicationSoft tissue impaction corresponds to codes for removal of impacted tooth, soft tissue (e.g., D7220).

inv-13: Partial and complete bone impaction

Partial bone impactionCrown not fully covered by bone; procedure requires flap elevation and may require bone removal to gain access.

Complete bone impactionCrown mostly or fully covered by bone; procedure requires elevation and removal of bone.

DocumentationIf partial or complete bone impaction is not evident from submitted documentation, a complete operative report or intraoral photos are required to justify the billed surgical code.

inv-14: Coronectomy

DefinitionCoronectomy: intentional partial removal of a tooth (typically lower third molars) performed to reduce risk of damage to the inferior alveolar nerve.

IndicationOffered when panoramic examination (possibly supplemented by cone beam CT) documents moderate-to-high risk to the inferior alveolar nerve.

Patient selectionGenerally performed on lower third molars (occasionally lower second molars); more appropriate in older individuals due to nerve-tolerance considerations.