CurrentUnitedHealthcarePolicy DCP022.13

Non-Surgical Extractions

Defines clinical indications, description, and coding references for non-surgical (routine) dental tooth extractions for UnitedHealthcare dental plans; intended for providers performing or authorizing extractions and for benefit determination in member-specific plans.

Policy Summary

PayerUnitedHealthcare

PolicyNon-Surgical Extractions

Policy CodePolicy DCP022.13

Change TypeAdministrative (references updated)

Effective DateJan 1, 2026

Next Review Date

Key ActionCheck member benefits and prior authorization requirements before performing listed CDT procedures (e.g., D7111, D7140).

SourceLink

POLICY UPDATE CHANGES

Updated References section to reflect the most current information and archived previous policy version DCG022.12.

8listed indications for non-surgical extractions

2CDT procedure codes cited

2026-01-01effective date

Coverage Criteria for Non-surgical Tooth Extractions

Indications (Coverage Criteria)

Covered when ONE OR MORE of the following clinical indications are present:

Policy Summary

PayerUnitedHealthcare

PolicyNon-Surgical Extractions

Policy CodePolicy DCP022.13

Change TypeAdministrative (references updated)

Effective DateJan 1, 2026

Next Review Date

Key ActionCheck member benefits and prior authorization requirements before performing listed CDT procedures (e.g., D7111, D7140).

SourceLink

On This Page

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The inclusion of a procedure code in this guideline does not by itself mean the service is covered. Listing of a code in this guideline does not imply that the service described by the code is a covered or noncovered health service; benefit coverage is determined by the member specific benefit plan document and any applicable laws or mandates. Prior to providing services, verify member benefits and prior authorization requirements because the member-specific plan governs coverage and reimbursement.

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Coverage tied to member-specific plan

Coverage determinations for listed CDT codes depend on the member specific benefit plan. Listing of a code does not imply coverage; benefit coverage is determined by the member specific benefit plan document and applicable law. Before using this policy, check the member specific benefit plan document and any applicable federal or state mandates. In the event of a conflict, the member specific benefit plan document governs.

Listing of a code does not imply coverage or payment
Check member specific benefit plan document and applicable law

Prior Authorization

Prior authorization may be required

Prior authorization may be required for certain procedures and CDT codes depending on the member specific benefit plan. Providers must verify prior authorization requirements and obtain authorization when required before rendering services to avoid potential claim denial.

Prior authorization requirements vary by plan and code
Verify and obtain prior authorization when required

Documentation Required

Required clinical documentation

Providers should document the clinical indication for extraction (for example: non-restorable tooth, failed endodontic therapy, poor prognosis, supernumerary tooth, or coronal remnants) and include relevant clinical findings in the record. Documentation should support medical necessity and the specific procedure code billed (e.g., D7111, D7140).

Document clinical indication for extraction (non-restorable, failed endo, poor prognosis, supernumerary, coronal remnants, etc.)
Include clinical findings and rationale that support the specific CDT code billed (e.g., D7111, D7140)

Background

Non-surgical (routine) extractions are performed for erupted teeth using instruments to separate the periodontium from the tooth and remove the tooth. The procedure typically includes removal of tooth structure, minor smoothing of the socket, and suturing if indicated. Indications commonly include non-restorable teeth, failed endodontics, poor prognosis, supernumerary or crowding teeth, orthodontic considerations, primary teeth interfering with eruption, and teeth interfering with planned prosthodontics.

OpenPayer

Non-Surgical Extractions

Coverage Criteria for Non-surgical Tooth Extractions

Procedure Codes

Provider Actions, Documentation, and Prior Authorization

Background

Definitions

D7111	Extraction, coronal remnants - primary tooth.
D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)