CurrentUnitedHealthcarePolicy DCPO27.14

Oral Surgery: Miscellaneous Surgical Procedures

Defines clinical indications, exclusions, applicable CDT procedure codes, and guidance for coverage determinations for various oral surgery procedures (oroantral fistula closure, primary closure of sinus perforation, tooth reimplantation/stabilization, surgical repositioning, sinus augmentation, salivary gland/duct procedures). Applies to UnitedHealthcare dental plans; member benefit documents govern final coverage.

Policy Summary

PayerUnitedHealthcare

PolicyOral Surgery: Miscellaneous Surgical Procedures

Policy CodePolicy DCPO27.14

Change TypeCodes removed / References updated

Effective DateAug 1, 2025

Next Review Date

Key ActionConfirm coverage by referencing the member specific benefit plan document and applicable federal/state mandates; benefit plan governs in conflicts.

POLICY UPDATE CHANGES

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

Supporting Information Updated References section to reflect the most current information

13Listed CDT procedure codes

5CPT codes removed in latest revision

Coverage Summary

This policy addresses miscellaneous oral surgery procedures including oroantral fistula closure, primary closure of sinus perforation, tooth reimplantation/stabilization and transplantation, surgical repositioning of teeth, harvest of autogenous bone, sinus augmentation (lateral and vertical approaches), salivary gland and duct procedures, and other unspecified oral surgery procedures (applicable CDT codes listed for reference). It applies to UnitedHealthcare dental plans; the member specific benefit plan document and any applicable federal/state mandates govern coverage determinations and prevail in the event of a conflict.

Medical Necessity Criteria (by procedure)

Oroantral Fistula

Covered when ALL of the following are met:

ALL of the following

Oroantral fistula present (an open connection between the maxillary sinus and oral cavity)
Surgical repair is performed (fistula will not heal spontaneously and must be surgically repaired)

Primary Closure of a Sinus Perforation

Indicated when ALL of the following are met:

Large sinus perforation resulting from routine tooth extraction, retrieval of root tips, or implant placementZmm (document shows "Zmm" - numeric threshold unclear)

Document shows 'Zmm' - numeric threshold unclear

Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced Tooth - Indications

Indicated when ANY of the following traumatic injury types are present:

ANY of the following

Subluxation injuries to permanent teeth
Lateral luxation injuries of primary and permanent teeth
Avulsion of permanent teeth
Extrusion injuries of < 3 mm in an immature developing primary tooth< 3 mm

Tooth Reimplantation and/or Stabilization - Contraindications / Not Indicated

Not indicated when ANY of the following are present:

ANY of the following

Intrusion injuries to primary teeth when the apex is displaced toward the permanent tooth germ
Primary teeth if injury is severe or tooth is near exfoliation
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
Lack of alveolar integrity
Tooth has been out of the oral cavity for 60 minutes or more60 minutes

Surgical Repositioning of Teeth

Indicated when ALL of the following are met:

ALL of the following

Displacement injuries to permanent teeth requiring surgical repositioning
Extrusion of teeth with crown/root fractures to prepare for restoration of permanent teeth

Sinus Augmentation Procedures

Indicated when ALL of the following are met:

Poor bone quality and/or quantity that would contraindicate implant placement

Sinus Augmentation - Not Indicated

Not indicated when ANY of the following are present:

Conditions blocking the ventilation and clearance of the maxillary sinus are present

Salivary Gland and Duct Procedures

Indicated when ALL of the following are met:

ALL of the following

Pathology amenable to salivary gland/duct procedures (e.g., removal of sialoliths, excision of gland or portions, repair of salivary fistulas or duct defects)
Procedure may be completed intraorally or extraorally as clinically appropriate

Salivary Gland and Duct Procedures - Not Indicated

Not indicated when ANY of the following patient factors are present:

ANY of the following

Individuals taking medications that negatively affect healing (examples include but not limited to immunosuppressive agents, corticosteroids, anticoagulants, NSAIDs, nicotine)
Individuals with an unmanaged medical condition (examples include but not limited to metabolic, cardiovascular, autoimmune/inflammatory, or genetic conditions that affect collagen synthesis)

Applicable Procedure Codes

Applicable CDT procedure codes (reference only)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	Sialolithotomy (duplicate code listed in document)

1–10 of 14

1/2

Removed CPT codes (per revision history)CPTNot Covered

21210	Removed per 08/01/2025 summary of changes
21215	Removed per 08/01/2025 summary of changes
30580	Removed per 08/01/2025 summary of changes
41899	Removed per 08/01/2025 summary of changes
42699	Removed per 08/01/2025 summary of changes

Provider Actions & Billing Guidance

Documentation Required

Reference member-specific benefit plan

Confirm coverage by referencing the member-specific benefit plan document and any applicable federal or state mandates; the member-specific benefit plan governs in the event of conflicts.

Documentation Required

Clinical indication documentation

Document the clinical indication to show it matches the policy criteria. Examples include presence of an oroantral fistula, size of a sinus perforation, type of tooth injury (subluxation, lateral luxation, avulsion, extrusion), time a tooth was out of the oral cavity, and relevant medical comorbidities or medications that affect healing.

Billing Rule

Use CDT codes for reporting

Report the applicable CDT procedure code corresponding to the performed oral surgery procedure; listing of codes is for reference only and is not a guarantee of coverage or payment.

D7260
D7261
D7270
D7272
D7290
D7295
D7951
D7952
D7979
D7980
D7981
D7982
D7983
D7999

Denial Risk

Exclusion risk due to medications or unmanaged conditions

Claims for salivary gland and duct procedures may be considered not indicated and denied if the patient is taking medications that negatively affect healing or has unmanaged medical conditions as listed in the policy.

Immunosuppressive agents
Corticosteroids
Anticoagulants
NSAIDs
Nicotine
Unmanaged metabolic, cardiovascular, autoimmune/inflammatory, or genetic conditions affecting collagen synthesis

Background & Supporting Evidence

These oral surgery procedures treat conditions that may arise from infection, radiation therapy, trauma, or tooth extractions. Examples include closure of oroantral fistulae that will not heal spontaneously, primary closure of large sinus perforations due to extractions or implant placement, tooth reimplantation or stabilization for subluxation/lateral luxation/avulsion/extrusion injuries, surgical repositioning for displacement injuries, sinus augmentation when bone quantity/quality contraindicates implant placement, and salivary gland or duct procedures such as sialolith removal or gland excision.

Some procedures that are medical in nature may be considered under the member’s medical benefit rather than the dental benefit; members’ Certificate of Coverage and health plan documentation should be referenced to determine benefit assignment. The policy’s applicable CDT codes are provided for reference and do not guarantee coverage or payment.

Per CA AB2585, while not common in dentistry, nonpharmacologic pain management strategies should be encouraged when appropriate.

The 08/01/2025 revision removed listed CPT codes (21210, 21215, 30580, 41899, 42699) from the policy and updated references.

Systematic review/meta-analysis (Raghoebar et al. 2019) of maxillary sinus floor augmentation with the lateral window technique included prospective studies with follow-up ≥ 5 years and a < 6 mm residual bone height inclusion criterion; reported overall 5‑year implant survival ranged from 88.6% to 100%.

Definitions

AvulsionComplete displacement of the tooth out of socket; periodontal ligament severed; alveolus fracture may occur.

ExtrusionPartial axial displacement of the tooth from the socket; partial avulsion; periodontal ligament usually torn.

IntrusionApical displacement of tooth into the alveolar bone; tooth driven into socket compressing periodontal ligament.

Lateral LuxationDisplacement of the tooth in a direction other than axially, with torn periodontal ligament and contusion/fracture of alveolar bone.

Oroantral FistulaAn open connection between the maxillary sinus and oral cavity, usually caused by extraction of maxillary posterior teeth.

Sinus AugmentationSurgical procedure elevating the floor of the sinus and placing bone grafts to allow adequate bone for dental implants or repair of defects.

SubluxationInjury to tooth-supporting structures with abnormal loosening but without tooth displacement.

OpenPayer

Oral Surgery: Miscellaneous Surgical Procedures

Coverage Summary

Medical Necessity Criteria (by procedure)

Applicable Procedure Codes

Provider Actions & Billing Guidance

Background & Supporting Evidence

Revision History