CurrentUnitedHealthcarePolicy DCPO05.12

Surgical and Partial Extractions of Erupted Teeth and Removal of Retained Roots

Defines indications and non-indications for surgical extraction of erupted teeth, surgical removal of residual roots, and coverage stance on partial extraction (socket shield) for immediate implant placement for UnitedHealthcare dental plans; includes applicable CDT procedure codes, clinical evidence summary, and revision history.

Policy Summary

PayerUnitedHealthcare

PolicySurgical and Partial Extractions of Erupted Teeth and Removal of Retained Roots

Policy CodePolicy DCPO05.12

Change TypeRevised

Effective DateJun 1, 2025

Next Review Date

Key ActionProvider must document clinical indication matching one of the listed criteria to support surgical extraction claims and reference the member-specific benefit plan for coverage decisions.

POLICY UPDATE CHANGES

Applicable Codes Removed CDT code D7922; Supporting Information Updated; FDA section updated; previous policy version archived (DCPO05.11).

3Procedure codes listed

1Non-indicated technique (socket shield)

Coverage Summary

Background: Surgical extraction involves removal of a tooth that does not safely allow a non-surgical approach and typically requires an incision, elevation, and bone removal. The policy also defines the Partial Extraction for Immediate Implant Placement (Socket Shield Technique) as a method preserving the buccal two-thirds of the root in the socket to potentially maintain the periodontium, bundle bone, and buccal bone and improve esthetic/contour outcomes.

Medical Necessity Criteria

Surgical Extraction of an Erupted Tooth - Medically Indicated

Surgical Extraction of an Erupted Tooth is indicated when ANY of the following are present:

ANY of the following

Erupted teeth with unusual root morphology (dilacerations, cementosis)
When fused to an adjacent tooth
Erupted teeth with developmental abnormalities that would make non-surgical extraction unsafe or cause harm
In the presence of periapical lesions
When tooth has been crowned or been treated endodontically
For maxillary posterior teeth whose roots extend into the maxillary sinus
The fracture of a tooth or roots during a non-surgical extraction procedure

ref_exactly_echoed_as_requested_ref_in_prompt___must_match_the_input_ref__DO_NOT_CHANGE___b1_0_title_must_be_the_tree_title_from_brief_and_include_it_exactly_as_given_refers_to_criteria_trees_index_0_ref_b1_0_title_which_should_be_present_in_this_block_but_only_in_specified_fields_below_if_required____Please_echo_ref_field_but_also_include_title_field_below_but_keep_ref_field_exactly_as_requested_b1_0_title_should_be_in_title_field_and_match_the_brief___Surgical Extraction of an Erupted Tooth - Medically Indicated

titleSurgical Extraction of an Erupted Tooth - Medically Indicated_also_present_for_searchability_and_integrity_purposes_but_do_not_change_ref_field_b1_0_title_field_should_match_brief_exactly_and_be_included_but_not_repeat_the_ref_field_below_should_be_present_as_title_field_and_exact_text_from_brief_Surgical Extraction of an Erupted Tooth - Medically Indicated

Surgical Removal of Residual Tooth Roots - Medically Indicated

Surgical Removal of Residual Tooth Roots is indicated when ALL of the following are met:

Tooth roots or fragments of tooth roots remain in the bone following a previous incomplete tooth extraction

Partial Extraction for Immediate Implant Placement (Socket Shield Technique)

Coverage stance:

Partial Extraction for Immediate Implant Placement (socket shield technique) is not indicated due to insufficient evidence of efficacy

Provider Actions

Documentation Required

Document indication for surgical extraction

Provider must document clinical indication matching one of the listed criteria (e.g., unusual root morphology, fused tooth, periapical lesion, crowned/endodontically treated tooth, root fracture during non-surgical extraction, or roots extending into maxillary sinus) to support surgical extraction claims.

D7210

Documentation Required

Document retained root fragments for D7250

Provider must document that tooth roots or fragments remain in bone following an incomplete extraction to support surgical removal of residual roots (D7250).

D7250

Billing Rule

Socket shield technique not indicated

Partial extraction for immediate implant placement (socket shield; D7252) is identified as not indicated due to insufficient evidence; member benefit plan and terms govern coverage, so claim may be denied or not covered absent specific benefit language supporting it.

Note: D7252 (socket shield) is identified as not indicated and coverage depends on member benefit language.

Documentation Required

Reference member-specific benefit plan

Before determining coverage, providers must reference the member-specific benefit plan document and any applicable federal or state mandates as those govern coverage decisions.

Background, Evidence & Definitions

The socket shield technique (partial extraction therapy, root membrane technique, partial root retention) preserves the buccal two-thirds of the root vertically to maintain the periodontium and buccal bone with the goal of improving esthetic outcomes for implant rehabilitation.

Clinical evidence is limited and mixed: systematic reviews (Oliva et al. 2023; Ogawa et al. 2022) report high implant survival rates and some benefit for marginal bone and esthetic scores but note study limitations (short follow-up, low-quality designs) and complications rates reported (including shield exposure, infection).

Coverage position: Routine implementation of the socket shield technique is not recommended due to insufficient long-term evidence and further high-quality research is needed before recommending SST for routine clinical implementation.

Study / Source	Findings
Oliva et al. 2023 systematic review	Implant survival rate 98.6% with socket shield technique (SST); marginal bone loss less and pink esthetic score higher with SST; authors concluded results are encouraging but further long-term research is needed before routine implementation.
Ogawa et al. 2022 systematic review	Included 20 studies (274 patients); treatment successful in 248 implants; complication/adverse event rate 9.5% (internal/external shield exposure, osseointegration failure, shield mobility, infection); limited by low-quality evidence and short follow-up; further high-quality research required.

Term	Definition
Partial Extraction/Socket Shield Technique	A technique in which the buccal two-thirds of the root in the socket is preserved vertically (also called socket shield, partial extraction therapy, root membrane technique) to maintain periodontium, bundle bone, and buccal bone and potentially improve esthetic contouring of implant rehabilitation.
Surgical Extraction of an Erupted Tooth	A tooth requiring removal of bone and/or sectioning of the tooth, including elevation of a mucoperiosteal flap if indicated; includes cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and closure; surgical extraction involves incision, elevation, and bone removal.
Surgical Removal of Residual Tooth Roots	A cutting procedure that includes cutting of soft tissue and bone, removal of tooth structure and closure when roots or fragments remain in the bone following an incomplete extraction.

Policy Summary

PayerUnitedHealthcare

PolicySurgical and Partial Extractions of Erupted Teeth and Removal of Retained Roots

Policy CodePolicy DCPO05.12

Change TypeRevised

Effective DateJun 1, 2025

Next Review Date

Key ActionProvider must document clinical indication matching one of the listed criteria to support surgical extraction claims and reference the member-specific benefit plan for coverage decisions.

On This Page

OpenPayer

Surgical and Partial Extractions of Erupted Teeth and Removal of Retained Roots

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions

Background, Evidence & Definitions

Revision History

D7210	Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated
D7250	Removal of residual tooth roots (cutting procedure)
D7252	Partial extraction for immediate implant placement