CurrentUnitedHealthcarePolicy DCPO05.12

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

Defines indications, coding, and evidence-based stance for surgical extraction of erupted teeth, surgical removal of residual roots, and the socket shield (partial extraction) technique for immediate implant placement; intended for providers administering UnitedHealthcare dental benefits.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy DCPO05.12

Change TypeCode removal and supporting info updated

Effective DateJun 1, 2025

Next Review Date

Key ActionVerify member-specific plan for prior authorization requirements and coverage determinations before providing services.

SourceLink

POLICY UPDATE CHANGES

Applicable CDT code D7922 was removed from the applicable codes list.

Supporting information and FDA section were updated.

Archived previous policy version DCPO05.11.

3distinct procedures

3primary CDT codes

98.6%reported implant survival

9.5%reported complication rate

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Coverage Criteria

Surgical Extraction Indications

Surgical extraction is indicated when ANY of the following conditions are present:

Surgical extraction indications: 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; fracture of a tooth or roots during a non-surgical extraction procedure.

Combined from listed indications in the policy.

Removal of Residual Tooth Roots

Covered when ALL of the following are met:

Residual root removal: Tooth roots or fragments of tooth roots remain in the bone following a previous incomplete tooth extraction.

Applies to surgical removal of residual tooth roots (cutting procedure).

Partial Extraction/Socket Shield

Policy stance:

Socket shield technique stance: Partial extraction for immediate implant placement (socket shield technique) is not indicated due to insufficient evidence of efficacy.

Although systematic reviews report high implant survival and some favorable outcomes, the policy concludes that evidence is insufficient to recommend routine use.

Supporting clinical evidence (summary): Systematic reviews report encouraging results: Oliva et al. (2023) found a 98.6% implant survival rate with reduced marginal bone loss and improved esthetic scores but noted need for further long-term research; Ogawa et al. (2022) reported a 9.5% complication/adverse event rate and limited high-quality data. These findings do not establish sufficient evidence for routine indication.

Included to explain the rationale for the stance.

Anatomical consideration: The socket shield technique preserves the buccal two-thirds of the root vertically to maintain the periodontium and buccal bone with the aim of improving esthetic outcomes in immediate implant placement.

Technique description from policy background; use of the technique remains investigational per policy.

Partial Extraction for Immediate Implant Placement (socket shield) is not indicated due to insufficient evidence of efficacy. This technique, also referred to as the socket shield technique, preserves a portion of the tooth root adjacent to the buccal plate during immediate implant placement; however, current policy does not support its use as an indicated procedure.

The socket shield technique for partial extraction and immediate implant placement is considered not indicated because available evidence is insufficient to establish consistent efficacy. Although emerging studies report promising short-term outcomes, the policy concludes there is not yet adequate, high-quality data to demonstrate predictable clinical benefit; therefore the procedure is not supported as an indicated treatment option.

Provider Actions and Billing Guidance

Prior Authorization

Prior Authorization Required

Verify prior authorization requirements with the member's plan before scheduling or performing services. Procedure codes provided here are for reference only; the member-specific benefit plan and any applicable mandates determine prior authorization and coverage requirements.

Reference codes (example): D7210, D7250, D7252 — verify these and any additional procedure codes with the member plan for prior authorization rules.
Confirm whether prior authorization is required for extractions, removal of residual roots, or partial extractions for immediate implant placement under the member's plan.

Documentation Required

Provider Billing and Documentation

Providers should confirm billing and documentation expectations with the member-specific plan prior to claim submission. Maintain operative notes, radiographs, and any documentation supporting medical necessity in the patient record to support coverage determinations.

Document clinical indication, procedure details, and any complications or additional procedures performed.
Retain radiographic and pathology reports when applicable to substantiate the procedure.

Note

Member Plan Governs

The member-specific benefit plan governs coverage decisions. When there is any discrepancy between this Dental Clinical Policy and the member's plan document or applicable mandates, the member-specific plan and mandates prevail.

Always check the member's plan for covered services, exclusions, prior authorization, and any state or federal mandates that may apply.
Do not rely solely on code lists in this guideline to determine coverage eligibility.

Billing Rule

Code Inclusion Is Not Coverage Guarantee

Code lists included in this guideline are for reference only and do not guarantee coverage or payment. Benefit determinations and reimbursement rights are based on the member-specific benefit plan document and applicable laws.

Examples of codes referenced: D7210, D7250, D7252 — presence here is not a coverage guarantee.
Other policies and guidelines may apply; confirm all requirements with the member's plan.

Background

Surgical extraction refers to removal of a tooth when non-surgical techniques are unsafe or inadequate and often requires incision, elevation, and removal of bone and/or sectioning of the tooth. These procedures are performed in clinical situations such as unusual root morphology, roots fractured during prior extractions, teeth with developmental abnormalities, or when access to the root is limited. The socket shield technique is a distinct partial-extraction method that preserves part of the root to maintain the periodontal apparatus and buccal bone during immediate implant placement, but it is addressed separately in this policy due to limited evidence supporting its efficacy.

Definitions

Partial Extraction (Socket Shield) — definition and brief description

TermPartial Extraction for Immediate Implant Placement (Socket Shield)

DefinitionA technique in which the buccal two-thirds of the root in the socket is preserved vertically.

Clinical intentPreserve periodontium and buccal bone to support esthetic outcomes for immediate implant placement.

Surgical Extraction of an Erupted Tooth — definition

TermSurgical Extraction of an Erupted Tooth

DefinitionA tooth requiring removal of bone and/or sectioning of the tooth, including elevation of a mucoperiosteal flap if indicated; includes related cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone, and closure.

Typical componentsMay involve bone removal, tooth sectioning, flap elevation, smoothing of socket, and closure.

Surgical Removal of Residual Tooth Roots — definition

TermSurgical Removal of Residual Tooth Roots

DefinitionCutting procedure that includes cutting of soft tissue and bone, removal of tooth structure, and closure for retained roots after incomplete extraction.

Indication contextApplies when tooth roots or fragments remain in bone following a previous incomplete extraction.

OpenPayer

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

Coverage Criteria

Coding and Billing Codes

Provider Actions and Billing Guidance

Background

Definitions

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