Medical necessity criteria
Number: 015
Update
Subject: Criteria for the removal of impacted teeth
Reviewed: August 16, 2023
Important note
This Clinical Policy Bulletin determines whether certain services or supplies are medically necessary, experimental, and investigational, or cosmetic. Aetna® has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence -based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Bulletin. The discussion, analysis, conclusions, and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute an opinion by Aetna and are made without any intent to defame.
Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. CPBs include references to standard HIPAA compliant code sets to assist with search functions and to facilitate billing and payment for covered services. New and revised codes are added to the CPBs as they are updated. When billing, you must use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.
Each benefit plan defines which services are covered, which are excluded and which are subject to dollar caps or other limits. Members and their dentists will need to refer to the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply.
The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.
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Policy
An impacted tooth (whether it is a third molar, supernumerary tooth or any other tooth) is one that is so positioned in the arch that it probably will not erupt into function by the middle of the third decade and thereby constitutes pathology with dental and medical consequences. To limit known risks and complications associated with the surgery, it is medically appropriate and surgically prudent to remove impacted third molars before the middle of the third decade and before the completion of root development. The middle of the third decade is defined as age 25. However, before the middle of the third decade, if an impacted tooth is so positioned that it cannot erupt into function, and the root development is essentially complete, it [the impacted tooth] constitutes pathology that has dental and medical consequences.
An impacted tooth with completed root formation that is totally covered by bone in a patient beyond the third decade, and does not meet the indications for surgery, should not be removed. There are few indications for removal of bone-impacted teeth in children and young adolescents (ages 9 through 15) unless specific criteria are met.
The following clinical conditions meet medical necessity and/or pathologic criteria for the purposes of determining benefits coverage of the removal of impacted third molars under designated dental plans:
Medical necessity criteria
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Documentation required |
|---|---|
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Therapy management for certain medical conditions (for example, pre-radiation, trauma) |
Current dated panoramic / periapical radiographs
Narrative of underlying medical condition and relationship to proposed treatment from dentist rendering service |
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Requisite for the completion of other necessary medical or dental treatments (for example, reconstruction, pre-prosthodontic, orthognathic) |
Current dated panoramic / periapical radiographs
Narrative of other necessary medical / dental treatment and relationship to proposed treatment from dentist rendering service |
Medical necessity criteria |
Therapy management for certain medical conditions (for example, pre-radiation, trauma) |
|---|---|
Documentation required |
Current dated panoramic / periapical radiographs
Narrative of underlying medical condition and relationship to proposed treatment from dentist rendering service |
Medical necessity criteria |
Requisite for the completion of other necessary medical or dental treatments (for example, reconstruction, pre-prosthodontic, orthognathic) |
Documentation required |
Current dated panoramic / periapical radiographs
Narrative of other necessary medical / dental treatment and relationship to proposed treatment from dentist rendering service |
Pathologic criteria
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Pathologic criteria |
Documentation required |
|---|---|
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Recurrent pericoronitis and chronic infection unsuccessfully treated with irrigation and antibiotic therapy |
Current available radiograph of the area
Letter of rationale to include narrative of treatment of previous infectious process |
|
Resorption of adjacent teeth |
Current dated panoramic / periapical radiographs
Narrative of other necessary medical / dental treatment and relationship to proposed treatment from dentist rendering service |
|
Unmanageable periodontal disease related to impaction (for example, probable defect to the follicular space on the distal aspect of second molar) |
Current dated radiograph of the area
Current dated periodontal charting, six points per tooth |
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Associated pathologic odontogenic cysts and tumors that are developing outside the confines of the tooth and considered to be located in an anatomical area independent of the tooth that requires additional surgery |
Current dated radiograph of the area |
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Tooth in the line of fracture |
Dated radiograph of trauma (preferably panorex) |
|
Preventive or prophylactic tooth removal, when indicated, for patients with medical or surgical conditions or treatments (for example, organ transplants, alloplastic implants, radiation therapy) |
Dated radiograph
Letter of rationale from the Oral Maxillo-Facial Surgeon (OMFS)
Letter of necessity from the treating physician |
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Insufficient arch length – as prescribed by orthodontist before or during orthodontic therapy |
Current dated panoramic radiograph of the area
Narrative from the orthodontist verifying arch length discrepancy |
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An impacted tooth positioned such that it will probably not erupt by the middle of the third decade |
Current dated panoramic radiograph of the area |
Pathologic criteria |
Recurrent pericoronitis and chronic infection unsuccessfully treated with irrigation and antibiotic therapy |
|---|---|
Documentation required |
Current available radiograph of the area
Letter of rationale to include narrative of treatment of previous infectious process |
Pathologic criteria |
Resorption of adjacent teeth |
Documentation required |
Current dated panoramic / periapical radiographs
Narrative of other necessary medical / dental treatment and relationship to proposed treatment from dentist rendering service |
Pathologic criteria |
Unmanageable periodontal disease related to impaction (for example, probable defect to the follicular space on the distal aspect of second molar) |
Documentation required |
Current dated radiograph of the area
Current dated periodontal charting, six points per tooth |
Pathologic criteria |
Associated pathologic odontogenic cysts and tumors that are developing outside the confines of the tooth and considered to be located in an anatomical area independent of the tooth that requires additional surgery |
Documentation required |
Current dated radiograph of the area |
Pathologic criteria |
Tooth in the line of fracture |
Documentation required |
Dated radiograph of trauma (preferably panorex) |
Pathologic criteria |
Preventive or prophylactic tooth removal, when indicated, for patients with medical or surgical conditions or treatments (for example, organ transplants, alloplastic implants, radiation therapy) |
Documentation required |
Dated radiograph
Letter of rationale from the Oral Maxillo-Facial Surgeon (OMFS)
Letter of necessity from the treating physician |
Pathologic criteria |
Insufficient arch length – as prescribed by orthodontist before or during orthodontic therapy |
Documentation required |
Current dated panoramic radiograph of the area
Narrative from the orthodontist verifying arch length discrepancy |
Pathologic criteria |
An impacted tooth positioned such that it will probably not erupt by the middle of the third decade |
Documentation required |
Current dated panoramic radiograph of the area |
Background
The dental profession continues to debate the timing and clinical circumstances under which to remove impacted third-molar teeth. A review of the dental literature demonstrates support for various positions of either removing or not removing the impacted teeth. Long-term objective studies on retained nonfunctional third-molar and other bone-impacted teeth and the sequelae following removal of these teeth are ongoing. The assumption that the erupting third-molar teeth will cause anterior crowding of teeth is unsubstantiated by clinical research and is not considered an indication for the removal of the third-molar teeth.
Designated medical preconditions and the extensiveness of other surgical procedures may warrant the removal of impacted third-molar teeth.
Codes
D7220 - Removal of impacted tooth - soft tissue
D7230 - Removal of impacted tooth - partially bony
D7240 - Removal of impacted tooth - completely bony
D7241 - Removal of impacted tooth - completely bony, with unusual surgical complications
D7251 - Coronectomy - intentional partial tooth removal
Revision dates
Original policy: July 14, 2003
Updated: September 13, 2004; January 09, 2009; February 22, 2010; June 27, 2011; September 10, 2012; November 5, 2013; December 8, 2014; March 30, 2016; November 22, 2016; November 13, 2017; February 19, 2020; April 5, 2021; October 12, 2022; August 16, 2023
Revised: January 17, 2006; September 21, 2007
Medical Clinical Policy Bulletin 0082 and 0124
The above policy is based on the following references:
American Dental Association. CDT 2023 Dental Procedure Codes.
White Paper on Management of Third Molar Teeth (PDF). AAOMS. 2016. Accessed October 12, 2022.
Steed MB. The indications for third-molar extractions. Journal of the American Dental Association (PDF). 145(6). Accessed October 12, 2022.
Copyright 2023 American Dental Association. All rights reserved.
Property of Aetna. All rights reserved. Dental Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical/dental advice. This Dental Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical/dental advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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