Commercial

Medical Policy

Title:

Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth

Policy #:

04.00.05d

Policy

EXTRACTION OF BONY IMPACTED TEETH AND ASSOCIATED SERVICES

The extraction of completely or partially bony impacted teeth is covered and eligible for reimbursement consideration by the Company. However, individual member benefits must be verified because some group contracts exclude coverage for the extraction of bony impacted teeth.

When the extraction of completely or partially bony impacted teeth is covered, the following fees and services performed in association with the extraction are also covered and eligible for reimbursement consideration:

The provider procedure fee
Appropriate facility charges
The evaluation and management (E&M) service
The radiographs performed to determine the impacted state

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the physician's office, hospital, nursing home, home health agencies, therapies, other health care professionals, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request.

Guidelines

EXPOSURE OF IMPACTED OR UN-ERUPTED TEETH AND ASSOCIATED SERVICES
For most plans, the exposure of impacted or un-erupted teeth without extraction, by surgery or by other means (e.g., with a device), is not covered by the Company because it is not a covered benefit. Therefore, it is not eligible for reimbursement consideration.

For most plans, the following fees and services performed in association with the exposure of impacted or un-erupted teeth are not covered by the Company because it is not a covered benefit. Therefore, it is not eligible for reimbursement consideration:

The provider procedure fee
Appropriate facility charges
The E&M service
The radiographs performed to determine the impacted state

Description

The extraction of bony impacted teeth involves extracting teeth that are either completely or partially covered by bone. Any tooth has the potential to become impacted. However, the most common are the wisdom teeth because they are often the last to emerge, usually between the ages of 17 and 21.

A bony impacted tooth may remain stuck in the bone for various reasons. The area may become overcrowded and prevent the too

th from emerging. The tooth may also become twisted or displaced as it tries to emerge. While impacted teeth may often be painless and cause no apparent trouble, occasionally a partially emerged impacted tooth can trap food, plaque, and other debris causing

pericoronitis, a condition associated with inflammation and tenderness around the crown of an impacted tooth.

Impacted teeth may be treated by extraction or exposure. The exposure of impacted teeth involves uncovering

un-erupted teeth without extraction. Extraction is typically the preferred treatment for an impacted tooth because when the tooth roots of an impacted tooth are allowed to develop, they may wrap around sensitive facial nerves.

References

Company Benefit Contracts.

Coding

CPT Procedure Code Number(s)

THE FOLLOWING CODES REPRESENT RADIOLOGIC SERVICES ASSOCIATED WITH THE EXTRACTION OF BONY IMPACTED TEETH:

70300, 70310, 70320, 70355

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

K01.0 Embedded teeth

K01.1 Impacted teeth

HCPCS Level II Code Number(s)

D0220 Intraoral - periapical, first film

D0230 Intraoral - periapical, each additional film

D0330 Panoramic film

D7230 Extraction of impacted tooth - partially bony

D7240 Extraction of impacted tooth - completely bony

D7241 Removal of impacted tooth - completely bony, with unusual surgical complications

THE FOLLOWING CODES REPRESENT NONCOVERED SERVICES FOR ALL INDIVIDUALS:

D7280 Surgical access of an unerupted tooth

D7283 Placement of device to facilitate eruption of impacted tooth

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 04.00.05d:

04/01/2026	This policy has been reviewed and reissued to communicate the Company’s continuing position on extraction of bony impacted teeth and exposure of impacted teeth.
04/02/2025	This policy has been reviewed and reissued to communicate the Company’s continuing position on Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth.
09/18/2024	This policy has been reviewed and reissued to communicate the Company’s continuing position on Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth.
04/05/2023	This policy has been reissued in accordance with the Company's annual review process.
06/29/2022	The policy has been reviewed and reissued to communicate the Company’s continuing position on Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth.

11/03/2021

This policy has been reissued in accordance with the Company's annual review process.

12/16/2020	This policy has been reissued in accordance with the Company's annual review process.
12/31/2019	This policy has been reissued in accordance with the Company's annual review process.

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date:

3/26/2014

Version Issued Date: