CurrentUnitedHealthcarePolicy DCP027.14

Oral Surgery: Miscellaneous Surgical Procedures

Coverage guidance for a set of oral and maxillofacial surgical procedures (e.g., oroantral fistula closure, sinus perforation closure, tooth reimplantation, sinus augmentation, salivary gland/duct procedures) that affect UnitedHealthcare members and dental/oral surgery providers.

Policy Summary

PayerUnitedHealthcare

PolicyOral Surgery: Miscellaneous Surgical Procedures

Policy CodePolicy DCP027.14

Change TypeAdministrative code list updatereferences updated

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionDetermine benefit coverage per the member's Certificate of Coverage and verify prior authorization requirements with the member's plan.

SourceLink

POLICY UPDATE CHANGES

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

Updated References section to reflect the most current information.

Archived previous policy version DCP027.13.

~10procedure codes provided in Applicable Codes

≥2 mmsinus perforation size threshold for primary closure

60 minmax out-of-mouth time before reimplantation not indicated

≥5 yrsfollow-up horizon in sinus augmentation review

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Coverage Criteria — Oral & Maxillofacial Procedures

Oroantral Fistula Closure

Covered when the following condition applies:

Oroantral Fistula Closure: Oroantral fistula that will not heal spontaneously and must be surgically repaired.

Primary Closure of Sinus Perforation

Primary closure is indicated when ALL of the following apply:

Primary Closure of Sinus Perforation: Sinus perforation that is large (≥ 2 mm) and results from routine tooth extraction, retrieval of root tips, or implant placement.>= 2mm

Tooth Reimplantation and Stabilization - Indications

Tooth reimplantation and stabilization are indicated when specific traumatic injury criteria are met:

Indications for reimplantation: Subluxation injuries to permanent teeth; lateral luxation injuries of primary and permanent teeth; extrusion injuries of < 3 mm in an immature developing primary tooth; or avulsion of permanent teeth.

Follow applicable clinical guidelines (e.g., IADT) for splinting and follow-up timing.

Tooth Reimplantation and Stabilization - Contraindications

Reimplantation is NOT indicated when ANY of the following are present:

Contraindications to reimplantation: Primary teeth with severe injury or near exfoliation; intrusion injuries to primary teeth when the apex is displaced toward the permanent tooth germ; extrusion injuries of a fully formed primary tooth that is mobile and near exfoliation or when the child is unable to cope with an emergency procedure; tooth that has been out of the oral cavity for 60 minutes or more; lack of alveolar integrity; or high risk of ankylosis.60 minutes

Extraction is recommended in these circumstances.

Surgical Repositioning of Teeth

Surgical repositioning is indicated when ALL of the following apply:

Surgical Repositioning of Teeth: Treatment of displacement injuries to permanent teeth; or extrusion of teeth with crown/root fractures to prepare permanent teeth for restoration.

Salivary Gland and Duct Procedures

Salivary gland and duct procedures are indicated for:

Salivary Procedures: Removal of sialoliths; surgical excision of part or all of a salivary gland; repair of salivary fistulas and defects of salivary ducts; procedures may be performed intraorally or extraorally.

Some oral surgery procedures may be not indicated when the patient has an unmanaged medical condition or is taking medications that impair healing. Examples include but are not limited to metabolic, cardiovascular, autoimmune/inflammatory, and genetic disorders affecting collagen synthesis. Medications that can negatively affect postoperative healing include immunosuppressive agents, corticosteroids, anticoagulants, NSAIDs, and nicotine. Providers should consider these factors when evaluating medical necessity and document how the patient’s comorbidities and medications influence the risk–benefit assessment for the planned procedure.

When considering tooth reimplantation, clinicians should also apply specific contraindication guidance: reimplantation is not indicated for primary teeth that are severely injured or near exfoliation; for intrusion injuries to primary teeth with the apex displaced toward the permanent tooth germ; for fully formed, mobile primary teeth near exfoliation or when the child cannot tolerate emergency care. Reimplantation is likewise contraindicated when the tooth has been out of the oral cavity for ≥ 60 minutes, when there is lack of alveolar integrity, or when there is a high risk of ankylosis. In these situations, extraction is recommended.

Applicable Procedure Codes & Key Coding Thresholds

Applicable CDT Procedure Codesmixed

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	Surgical sialolithotomy

1–10 of 14

1/2

Sinus perforation size for primary closure

Sinus perforation size threshold>= 2 mm

Indication contextDefects resulting from routine tooth extraction, retrieval of root tips, or implant placement

Coverage actionPrimary closure is indicated for large sinus perforations meeting the threshold

Provider Actions, Documentation & Billing Guidance

Prior Authorization

Prior authorization and benefit determination

Determine benefit coverage per the member's Certificate of Coverage and health plan documentation; services may be covered under the medical benefit when determined to be medical in nature. Prior authorization and benefit determination should follow the member-specific plan rules.

Note

Nonpharmacological pain management

Encourage and consider nonpharmacological pain management strategies (e.g., behavioral interventions, physical modalities) when appropriate, per CA AB2585 and best-practice pain management principles.

Documentation Required

Documentation requirement

Include the applicable CDT procedure code on all documentation and claims. Supporting documentation must demonstrate medical necessity (for example, defect size, clinical findings, imaging, operative report) to justify the procedure.

Background

Oral and maxillofacial surgical procedures address a range of defects and injuries from infection, trauma, extractions, radiation, or anatomic bone loss. Procedures such as tooth reimplantation and surgical repositioning manage traumatic displacement injuries (e.g., avulsion, lateral luxation, extrusion, intrusion, subluxation) and aim to restore tooth position, function, and periodontal health. Sinus augmentation procedures increase bone volume to enable implant placement when native bone quantity or quality is insufficient. Salivary gland and duct procedures treat obstructive sialoliths, repair fistulas, and remove diseased gland tissue. Treatment planning should account for patient-specific factors—including systemic conditions and medications that impair healing—which may alter indication or favor alternative management (for example, extraction rather than reimplantation when contraindications are present).

Definitions — Dental Trauma Terms

Avulsion

DefinitionComplete displacement of the tooth out of socket; the periodontal ligament is severed, and fracture of the alveolus may occur.

Common sourceAAPD (American Academy of Pediatric Dentistry)

Clinical implicationOften requires reimplantation or extraction and management of alveolar fracture

Extrusion

DefinitionPartial displacement of the tooth axially from the socket; partial Avulsion. The periodontal ligament is usually torn.

Common sourceAAPD

Clinical implication

Policy Revision History

2025-08-01code_list_updateLatest

Removed CPT codes 21210, 21215, 30580, 41899, and 42699 from the Applicable Codes list; References section updated and prior policy version DCP027.13 archived.