Criteria for the Removal of Impacted Teeth (015)

Number: 015
(Update)

Subject: Criteria for the Removal of Impacted Teeth

Reviewed: November 5, 2013

Important Note

This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made these decisions based on a review of currently available clinical information including:

  • Clinical outcome studies in the peer-reviewed published medical and dental 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 and dentists practicing in relevant clinical areas
  • Other relevant factors

We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

Each benefits 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 consult 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.

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 older than 25 that 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 Documentation required
1. 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
2. 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
Pathologic criteria
1. 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
2. Resorption of adjacent teeth
  • Current dated radiograph of the area
3. 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
4. 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
5. Tooth in the line of fracture
  • Dated radiograph of trauma (preferably panorex )
6. 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 OMFS
  • Letter of necessity from the treating physician
7. 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
8. 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

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 to either remove or not remove 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.

Codes1

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
Revised: January 17, 2006; September 21, 2007

Medical Clinical Policy Bulletin 0082:

The above policy is based on the following references:

1 American Dental Association. Current Dental Terminology, CDT-2011-2012: 57-58.*

2 Tulloch J F, Antczak M, Wilkes J W. The application of decision analysis to evaluate the need for extraction of asymptomatic third molars. J Oral Maxillofacial Surgery 1987; 45: 855-865.

3 Brickley M, Kay E J, Shepherd J. A decision analysis of lower third molar surgery. Med Decision Making 1993; 13:381.

4 Guralnick W, Wilkes J W, Aschaffenburg P H, Frazier H W, House J E, Chauncey H. Incidence of and progressive pathological changes associated with impacted third molar teeth. Abstract presented at IADR Annual Meeting, New Orleans, LA, and March 18-21, 1982.

5 Mercier P, Precious D. Risks and benefits of removal of impacted third molars. A critical review of the literature. Int J Oral Maxillofacial Surgery 1992; 21: 17-27.

6 Daley T D. Third molar prophylactic extraction: a review and analysis of the literature. General Dentistry 1996; (44) 4:310-321.

7 Ahlquist M, Grondahl H. Prevalence of impacted teeth and associated pathology in middle-aged and older Swedish women. Community Dent Oral Epidemiol 1991; 19: 116-119.

8 Von Wowem N, Nielsen H O. The fate of impacted third molars after the age of 20. Int J Oral Maxillofacial Surgery 1989; 18:277-280.

9 Eliasson S, Heimdahl A, Norendom A. Pathological changes related to long-term impaction of third molars. Int J Oral Maxillofacial Surgery 1989; 18: 210-212.

10 Garcia R I, Chauncey H The eruption of third molars in adults: a 10-year longitudinal study. Oral Surgery 1989; 68:9-13.

11 National Institutes of Health Consensus Development Conference: Removal of third molars. NIDR 1979.

12 Andreasen G, Bishara S E. Third molars: a review. Am J Orthod 1983; 83: 131-137.

13 Southard T E, Southard K A, Weeda L W. Mesial force from unerupted third molars. Am J Orthod Dentofac Ortho 1991; 99: 220-225.

14 National Institute for Clinical Excellence. Guidance for removal of wisdom teeth; March 27,2000; 1.4.

15 Myer S. Leonard, MD, DDS, Removing third molars, a review for the general practitioner, JADA, 123,2/92,77-86.

16 Bailit, H.L., Maryniuk, G.A., Braun, R. et al. Is periodontal disease the primary cause of tooth extraction in adults? JADA 114:40-45, 1987.

17 Lysell L., Rohlin M., A study of the indications used for removal of the mandibular third molar, International J of Oral-Maxillofacial Surgery, Vol 17, No.3, June 1988

18 Stanley, H.R., Alattar, M.,Collett, W.K., Strongfellow Jr., H.R. and Speigle, E.H., Pathological sequella of "neglected" impacted third molars, Oral Surg 64:567, 1987.

19 Ades, AG, Joondeph, DR, Little, RM, Chapko, MK. A long term study of the relationship of third molars to changes in the mandibular dental arch. Am J Ortho, 1990;97:323-325.

20 Eliasson, S, Heidahl, A, Nordenram, A. Pathologic changes related to long-term impaction of third molars. A radiographic study. Inter J Oral Maxiofac Surg 1989;18(4):210-212.

21 Parameters and Pathways 2000: Clinical practice guidelines for oral and maxillofacial surgery, AAOMS ParPath. 2000; Version 3.

22 American Association of Oral and Maxillofacial Surgeons (AAOMS). White paper on third molar data. Rosemont, IL: AAOMS; March 2010. Accessed May 23, 2011. Available at http://www.aaoms.org/docs/third_molar_white_paper.pdf.

23 American Association of Oral and Maxillofacial Surgeons (AAOMS). Statement of the American Association of Oral and Maxillofacial Surgeons concerning the management of selected clinical conditions and associated clinical procedures. Bone grafting after removal of impacted third molars. Rosemont, IL: AAOMS; March 2010. Accessed May 23, 2011. Available at http://www.aaoms.org/docs/practice_mgmt/condition_statements/bone_grafting.pdf.

24 American Association of Oral and Maxillofacial Surgeons (AAOMS). Statement of the American Association of Oral and Maxillofacial Surgeons concerning the management of selected clinical conditions and associated clinical procedures. The management of impacted third molar teeth. Rosemont, IL: AAOMS; March 2010.

* Copyright 2010 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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