Commercial

Policy

MPPolicyPub

COMMERCIAL MEMBERS

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​

EXPOSURE OF IMPACTED OR UN-ERUPTED TEETH AND ASSOCIATED SERVICES
The exposure of impacted or un-erupted teeth without extraction, by surgery or by other means (e.g., with a device), is not a covered benefit for commercial products of the Company and is, therefore, not eligible for reimbursement consideration.

The following fees and services performed in association with the exposure of impacted or un-erupted teeth are also not covered benefits and are, therefore, not eligible for reimbursement consideration:

• The provider procedure fee
• Appropriate facility charges
• The 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

Description

MPDescriptionPub

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

Coding

CPT Procedure Code Number(s)

ICD - 10 Procedure Code Number(s)

ICD - 10 Diagnosis Code Number(s)

HCPCS Level II Code Number(s)

Revenue Code Number(s)

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History