Currentpriority healthPolicy N/A

Oral Surgery & Dental Extractions Coverage Criteria

Defines when oral surgery and dental extraction procedures are considered medical treatments covered under the medical benefit and who is affected (members whose plan provides medical coverage for these services).

Policy Summary

Payerpriority health

PolicyOral Surgery & Dental Extractions Coverage Criteria

Policy CodePolicy N/A

Change TypeMinor/No material change

Effective Date03/01/2026

Next Review DateN/A

Key ActionObtain and submit prior authorization and supporting documentation demonstrating medical necessity when required for oral/maxillofacial procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

03/01/2026policy effective date

Dental benefit ordinarilyextractions stance

D0120-D9999dental codes excluded

29+CPT/HCPCS codes listed

Coverage Criteria for Oral Surgery and Dental Extractions

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Medically Necessary Oral Surgery

The following oral surgery procedures are considered medically necessary (not an all-inclusive list):

Included oral surgery procedures: Excision and/or biopsy of tumors and cysts of the jaw, cheek, lip, tongue, roof and floor of the mouth when pathological (histologic) examination is required (examples: myeloma; osteomyelitis; osteosarcoma; metastatic carcinoma; median palatal cyst; globulomaxillary cyst; giant cell tumor; chondrosarcoma; central ossifying fibroma; traumatic bone cyst).

From policy inclusions (chunks 2–3).

Fractures and traumatic care: Treatment of simple and complex fractures of the jaws and facial bones; repair of traumatic wounds; emergency care to stabilize dental structures following acute injury to sound, natural teeth; removal of foreign body hazardous to health that complicates a primary medical condition.

From policy inclusions (chunk 3).

Congenital and oncologic procedures: Surgical correction of congenital abnormalities (e.g., cleft lip and/or palate, including alveolar ridge closure and appliance preparation for bone grafting); treatment of oral and/or facial cancer including resections and related procedures to prevent/treat disease (e.g., resection for osteomyelitis).

From policy inclusions (chunk 3).

Soft tissue and salivary procedures: Marsupialization of ranula; excision of lingual frenum/frenulum when medically necessary for speech or restricted eating; surgery of accessory sinuses, salivary glands or ducts; external incision and drainage of abscess (cellulitis).

From policy inclusions (chunk 3).

Oral cavity procedures and complex suturing: Complicated suturing and procedures such as removal of midline palatal tori and lingual mandibular tori; anesthetic/sedation when administered in conjunction with a medically necessary oral surgery procedure; other oral cavity excision/biopsy procedures as clinically indicated.

From policy inclusions (chunk 3).

Medically Necessary Dental Extractions

Dental extractions — covered when meeting medical necessity conditions:

Medically necessary dental extraction: Extraction of sound, natural teeth is considered medically necessary when required in preparation for, or as part of, another medically necessary treatment or procedure that is not primarily dental in nature (for example, removal to prevent osteoradionecrosis in patients undergoing treatment for oral cancers).

Definition: sound tooth = tooth without evidence of current dental decay or other pathology (chunk 5).

Benefit and claim processing: Tooth extractions are subject to Dental benefits; upon request, medical claims for teeth extraction will be reviewed against policy and, if criteria are met, may be reprocessed for payment retrospectively.

Policy states extractions are generally dental benefit and may be reprocessed if criteria met (chunk 5).

Exclusions specific to extractions: Dental extractions of teeth that are not sound and routine tooth restoration procedures (including restoration following extraction) are considered not medically necessary under the medical benefit.

From policy exclusions (chunk 5).

Plan-specific limitation: MI Medicaid and Healthy Michigan Plan members: dental extractions are not a covered benefit through the health plan.

Policy note (chunk 5).

Medical necessity and review

General coverage stance and review process

Medical vs Dental: Tooth extractions are subject to dental benefits; medical claims for tooth extraction will be reviewed and may be reprocessed for payment retrospectively if policy criteria are met.

See policy statement on dental benefit ownership and claim re-processing (chunk 26, chunk 5).

Prior authorization and individual review: Prior authorization may be required for certain drugs, devices, services and procedures. When prior authorization is required, providers must submit documentation demonstrating medical necessity. Individual case review may allow coverage for investigational yet promising care with prior plan approval; determinations for experimental or unproven treatments are made by a Priority Health medical director or clinical pharmacist.

Medical necessity review and prior authorization process (chunk 29).

Documentation: Maintain documentation supporting medical necessity such as pathology reports for excision/biopsy, operative reports for fracture repair, treatment records demonstrating need for extraction as part of non-dental medically necessary treatment, and relevant ICD-10 diagnoses to support the medical condition.

Documentation expectations referenced across policy (chunks 2,3,5,29).

The medical benefit excludes services that are dental in nature. Examples of excluded dental specialties and restorative services include orthodontic, periodontic, endodontic, and prosthodontic services, as well as routine restorative dental care such as crowns, fillings, bridges, partial and full dentures. The policy also excludes dental applications like bite splints and metal-based occlusal appliances, and procedures tied to orthodontic treatment (e.g., frenectomy/frenulectomy performed for orthodontic reasons). Additionally, manual manipulation therapies, hypnosis, acupuncture (except where a commercial-plan rider allows acupuncture), biofeedback, vestibuloplasty, alveolectomy/alveoplasty related to dentition, and tooth implants are listed as not medically necessary when billed under the medical benefit.

Dental extractions of teeth that are not sound are considered not medically necessary and are excluded from coverage under the medical benefit. The policy defines a sound tooth as one without evidence of current dental decay or other pathology; extractions of non-sound teeth (for dental reasons) should be billed to dental benefits and will not meet medical necessity under this policy.

Tooth extractions are generally the responsibility of the dental benefit. While the extraction of sound, natural teeth may be considered medically necessary when required as part of another non-dental medically necessary treatment (for example, removal to prevent osteoradionecrosis in oral cancer care), claims are treated as dental benefit claims. For MI Medicaid and Healthy Michigan Plan members, dental extractions are explicitly not a covered benefit through the health plan and should not be billed to the medical plan.

Dental procedure codes in the D-series are not covered when billed to the medical plan: specifically, D0120–D9999 are excluded from medical coverage. In addition, when medical services are billed using ICD-10 dental diagnosis codes listed in the policy (see the ICD-10 dental Dx list), those claims are considered not covered under the medical benefit. The policy also lists specific CPT codes that are not covered for any diagnosis (e.g., 40806, 40819, 90880, 90901, 97810–97814).

Extraction of unerupted, partially erupted, malpositioned, or impacted teeth (with or without attached follicular tissue) is listed as not medically necessary under the medical benefit and is excluded. The policy further excludes surgical preparation of the mouth for dentures and procedures tied to gum disease or orthodontic treatment. Restorative procedures following extractions (for example, tooth restoration after a medically necessary extraction) are also considered dental services and are not covered under the medical benefit.

Services that are dental in nature but billed to the medical plan will be treated as not covered. This includes procedures billed with dental procedure codes D0120–D9999 and medical claims submitted with the policy’s listed ICD-10 dental diagnosis codes. Providers should bill such services to the member’s dental plan; submitting them to the medical plan may result in denial or reprocessing to dental benefits.

Coding — Diagnosis and Procedure Codes

ICD-10 Supporting DiagnosesICD-10

C01-C10.9	Malignant neoplasm of oral cavity and pharynx
C41.0	Malignant neoplasm of bones of skull and face
C76.0	Malignant neoplasm of head, face and neck
D00.00-D00.08	Carcinoma in situ of lip, oral cavity and pharynx
D37.01-D37.09	Neoplasm of uncertain behavior of lip, oral cavity and pharynx
K09.8-K09.9	Cysts of oral region
K11.6	Mucocele of salivary gland
M27.2-M27.3	Inflammatory conditions of jaws / Alveolitis of jaws
Q35.1-Q37.9	Cleft lip or palate
Q38.1	Ankyloglossia

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CPT/HCPCS Codesmixed

21025	Excision of bone; mandible
21026	Excision of bone; facial bone(s)
21029	Removal by contouring of benign tumor of facial bone
21030	Excision of benign tumor or cyst of maxilla or zygoma
21031	Excision of torus mandibularis
21032	Excision of maxillary torus palatinus
21034	Excision of malignant tumor of maxilla or zygoma
21040	Excision of benign tumor or cyst of mandible
21044	Excision of malignant tumor of mandible
21045	Excision of malignant tumor of mandible; radical resection

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Oral cavity incision/biopsy/excision CPT codesCPT

41000	Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual
41005	Intraoral incision and drainage; sublingual, superficial
41006	Intraoral incision and drainage; sublingual, deep, supramylohyoid
41007	Intraoral incision and drainage; submental space
41008	Intraoral incision and drainage; submandibular space
41009	Intraoral incision and drainage; masticator space
41010	Incision of lingual frenum (frenotomy)
41015	Extraoral incision and drainage; sublingual
41016	Extraoral incision and drainage; submental
41017	Extraoral incision and drainage; submandibular

1–10 of 20

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Dentoalveolar and related proceduresCPT

41250	Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue
41251	Repair of laceration 2.5 cm or less; posterior one-third of tongue
41252	Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex
41510	Suture of tongue to lip for micrognathia (Douglas type procedure)
41520	Frenoplasty (surgical revision of frenum, e.g., with Z-plasty)
41800	Drainage of abscess, cyst, hematoma from dentoalveolar structures
41805	Removal of embedded foreign body from dentoalveolar structures; soft tissues
41806	Removal of embedded foreign body from dentoalveolar structures; bone
41820	Gingivectomy, excision gingiva, each quadrant
41821	Operculectomy, excision pericoronal tissues

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Palate, salivary gland, and abscess drainage CPT codesCPT

42100	Biopsy of palate, uvula
42104	Excision, lesion of palate, uvula; without closure
42106	Excision, lesion of palate, uvula; with simple primary closure
42107	Excision, lesion of palate, uvula; with local flap closure
42120	Resection of palate or extensive resection of lesion
42160	Destruction of lesion, palate or uvula (thermal, cryo or chemical)
42180	Repair, laceration of palate; up to 2 cm
42182	Repair, laceration of palate; over 2 cm or complex
42200	Palatoplasty for cleft palate, soft and/or hard palate only
42205	Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only

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Salivary gland and related proceduresCPT

42400	Biopsy of salivary gland; needle
42405	Biopsy of salivary gland; incisional
42408	Excision of sublingual salivary cyst (ranula)
42409	Marsupialization of sublingual salivary cyst (ranula)
42410	Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection
42415	Excision of parotid tumor; with preservation of facial nerve
42420	Excision of parotid tumor or gland; total, with dissection and preservation of facial nerve
42425	Excision of parotid tumor or gland; total, en bloc removal with sacrifice of facial nerve
42426	Excision of parotid tumor; total, with unilateral radical neck dissection
42440	Excision of submandibular (submaxillary) gland

1–10 of 12

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Explicitly not covered CPT codesCPTNot Covered

40806	Incision of labial frenum (frenotomy) - not covered
40819	Excision of frenum, labial or buccal (frenectomy) - not covered
90880	Hypnotherapy - not covered
90901	Biofeedback training - not covered
97810	Acupuncture initial 15 minutes - not covered
97811	Acupuncture additional 15 minutes - not covered
97813	Acupuncture with electrical stimulation initial - not covered
97814	Acupuncture with electrical stimulation additional - not covered

Dental extraction (D-codes)CPT

D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
D7210	Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth
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

ICD-10 dental diagnosis codes not covered when billed to medical planICD-10Not Covered

E08.630	Diabetes mellitus due to underlying condition with periodontal disease
E09.630	Drug or chemical induced diabetes mellitus with periodontal disease
E10.630	Type 1 diabetes mellitus with periodontal disease
E11.630	Type 2 diabetes mellitus with periodontal disease
E13.630	Other specified diabetes mellitus with periodontal disease
G47.63	Sleep related bruxism
K00.0-K08.59	Disorders of teeth and supporting structures
M26.20-M26.4	Anomalies of dental arch and tooth position
M26.70-M26.9	Dental alveolar or facial anomalies
F59	Unspecified behavioral syndromes associated with physiological disturbances and physical factors

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Coding inventory note

Coding inventory keyNo additional miscellaneous coding items listed in policy inventory.

Laceration size threshold (CPT)

Laceration size threshold2.5 cm is the sizing threshold between CPT 41250/41251 (≤2.5 cm) and CPT 41252 (>2.5 cm or complex)

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain oral and maxillofacial procedures and some codes that are designated under cosmetic/reconstructive surgery rules. When prior authorization is required, providers must submit documentation demonstrating medical necessity prior to delivery of the service.

Certain palatoplasty and related CPTs marked: 42180, 42182, 42200–42235, 42260, 42280–42281, 42299
Additional oral/maxillofacial procedure codes listed in policy may require prior authorization under cosmetic/reconstructive rules
Refer to Priority Health Provider Manual for complete prior authorization process

Documentation Required

Documentation to Support Medical Necessity

When prior authorization is required, providers must include sufficient documentation to support medical necessity. Maintain and submit relevant clinical records such as pathology and operative reports, imaging, and other diagnostic findings that justify the procedure.

Pathology/histology reports for excisions/biopsies
Operative reports detailing indication and extent of surgical procedure
Relevant imaging (radiographs, CT) supporting diagnosis and surgical need
Medical records documenting non-dental indication when extraction is for a medical procedure (e.g., oncology, fracture repair)

Denial Risk

Billing and Denial Triggers

Dental services billed with dental procedure codes (D0120–D9999) or medical services billed with dental diagnosis codes listed in the policy are not covered under the medical plan and may be denied. Claims for medical tooth extractions that meet policy criteria may be reconsidered upon request.

Dental procedure codes D0120–D9999: not covered under medical benefit
Medical services billed with listed dental ICD-10 diagnosis codes will be denied
Extractions of teeth that are not 'sound' are not medically necessary and will be denied
MI Medicaid and Healthy Michigan Plan members: dental extractions are not covered through the health plan

Prior Authorization

Provider Actions When Prior Authorization Is Required

For procedures subject to prior authorization, include the prior authorization number on claims and retain submitted supporting documentation in the medical record. If a service initially billed to medical is later determined to meet medical criteria, providers may request claim re-processing with supporting documentation.

Include prior authorization reference on claims when applicable
Retain copies of all submitted documentation (pathology, operative reports, imaging)
Submit requests for retrospective review only when documentation supports medical criteria

Background on Oral and Maxillofacial Surgery

Oral and maxillofacial surgery, for the purposes of this policy, encompasses the diagnosis and surgical management of diseases, injuries, and defects of the oral and facial regions. Medically necessary oral surgery examples include excision/biopsy of tumors and cysts requiring pathology, treatment of simple and complex facial fractures, repair of traumatic wounds, removal of hazardous foreign bodies, resection for osteomyelitis, surgery of salivary glands/ducts, marsupialization of ranula, treatment of oral/facial cancer, correction of congenital abnormalities (e.g., cleft lip/palate including alveolar ridge closure), and emergency stabilization of dental structures following acute injury. Anesthetic or sedation administered in conjunction with a medically necessary oral surgery procedure is also considered part of medically indicated treatment.

Definitions

Definition: sound tooth

DefinitionA 'sound' tooth is a tooth without evidence of current dental decay or other pathology.

Dental extractions: definitions and claims notes

Dental benefit responsibilityTooth extractions are subject to Dental benefits; medical coverage applies only when extraction meets medical necessity criteria.

Claim reprocessingUpon request, medical claims for tooth extraction will be reviewed against policy and may be reprocessed for payment retrospectively if criteria are met.

MI Medicaid / Healthy MichiganFor MI Medicaid and Healthy Michigan Plan members, dental extractions are not a covered benefit through the health plan.

Denial riskClaims for dental extractions billed to medical may be denied if the tooth is not 'sound' or the service is dental in nature.

Policy Summary

Payerpriority health

PolicyOral Surgery & Dental Extractions Coverage Criteria

Policy CodePolicy N/A

Change TypeMinor/No material change

Effective Date03/01/2026

Next Review DateN/A

Key ActionObtain and submit prior authorization and supporting documentation demonstrating medical necessity when required for oral/maxillofacial procedures.

SourceLink

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