Medicare Advantage

Medical Policy

Title:

Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth

Policy #:

MA04.002

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

Extraction of completely or partially bony impacted teeth or the exposure of impacted or un-erupted teeth without extraction, by surgery or by other means, is not covered by the Company, because these services are not covered by Medicare. Therefore, these services, including the following associated services, are not eligible for

reimbursement consideration:

Evaluation and Management service
Provider procedure fee
Facility charges
Radiographs performed to determine the impacted state

Guidelines

This policy is consistent with Medicare’s coverage determination.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, extraction of completely or partially bony impacted teeth or the exposure of impacted or un-erupted teeth without extraction, by surgery or by other means, is not covered under the medical benefits of the Company’s Medicare Advantage plans because they are not covered by Medicare. Therefore, these services are not eligible for reimbursement consideration.

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 tooth 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

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. §150 - Dental services. [CMS Web site]. 07/25/2025. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed March 4, 2026.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 16: General exclusions from coverage. §140 - Dental services exclusion. [CMS Web site]. 6/18/2025. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c16.pdf. Accessed Accessed March 4, 2026.

Coding

CPT Procedure Code Number(s)

NOT COVERED

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)

NOT COVERED

D0220 intraoral - periapical first radiographic image

D0230 intraoral - periapical each additional radiographic image

D0330 panoramic radiographic image

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

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 MA04.002:

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.
01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
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.
01/01/2015	This is a new policy.

Version Effective Date:

1/1/2024

Version Issued Date: