Criteria for the removal of impacted teeth (015)

Number: 015
(Updated)

Subject: Criteria for the removal of impacted teeth

Reviewed: April 5, 2021

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 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.

Visit the CMS coverage database

Policy^1,2

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.

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

Medical necessity criteria	Documentation required
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
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

Pathologic criteria	Documentation required
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
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
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
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
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 and/or manage impacted third-molar teeth. Third Molar Management, as described by the American Association of Oral and Maxillofacial Surgeons, is predicated on the best evidence-based data. Third molar teeth that are associated with pathology, or are at high risk of developing pathology, should be surgically managed. In the absence of pathology or significant risk of pathology, active clinical and radiographic surveillance is indicated.

A review of the dental literature demonstrates support for various positions to either remove or not remove the impacted teeth. There are a variety of recognized management choices for third molars, including removal, partial removal (coronectomy), retention with active clinical and radiographic surveillance and surgical exposure. When considering possible management choices, the likelihood that pathology may develop should be evaluated. 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.

Codes³

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
Revised: January 17, 2006; September 21, 2007

Medical Clinical Policy Bulletin 0082 and 0124

The above policy is based on the following references:

¹White Paper on Management of Third Molar Teeth (PDF). AAOMS. 2016. Accessed February 19, 2020.

²Steed MB. The indications for third-molar extractions. Journal of the American Dental Association (PDF). 145(6). Accessed February 19, 2020.

³American Dental Association. CDT 2021 Dental Procedure Codes.*

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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