Blue Cross Blue Shield FEP Dental
Class B Intermediate

D7111 Extraction coronal remnants, primary tooth

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth

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

D7250 Surgical removal of residual tooth roots (cutting procedure)

D7251 Coronectomy - intentional partial tooth removal, impacted teeth only

D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth

D7272 Tooth transplantation - includes splinting or stabilization

D7280 Surgical access of an unerupted tooth

D7310 Alveoloplasty in conjunction with extractions – per quadrant

D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

D7320 Alveoloplasty not in conjunction with extractions – per quadrant

D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

D7471 Removal of exostosis

D7485 Surgical reduction of tuberosity

D7510 Incision and drainage of abscess – intraoral soft tissue

D7910 Suture of recent small wounds up to 5 cm

D7953 Bone replacement graft for ridge preservation - per site - No review on anterior teeth. Posterior teeth reviewed to determine if covered or not. 3rd Molar extraction sites denied unless D7251 performed. Anterior teeth and approved posterior teeth, Limit 1 every 60 months

D7971 Excision of pericoronal gingiva

D7972 Reduction of fibrous tuberosity – Limit 1 every 6 months

D7999 Unspecified oral surgery procedure, by report

Class B Intermediate Notes:
 

• Restorations are covered benefits only when necessary to replace tooth structure due to fracture or decay.
   
• For reporting and benefit purposes, the completion date for crowns and fixed partial dentures is the cementation date. The completion date is the insertion date for removable prosthodontic appliances. For immediate dentures, the provider who fabricated the denture may be reimbursed for the service after insertion by another provider (e.g. oral surgeon).
   
• Tissue conditioning is considered inclusive when performed on the same day as the delivery of a denture or a reline/rebase.
   
• Bone replacement grafts for ridge preservation are limited to extraction sites when implants are approved for placement or when implant removal may be necessary.

Periodontal Services:

• Full mouth diagnostic quality radiographic images and/or a panoramic radiographic image including bitewings radiographs; labeled and dated (within 12 months of submitted procedure).
   
• Periodontal Charting: 6-point periodontal pocket depth charting as described by the ADA and AAP labeled and dated (within 12 months of submitted procedure).
   
• Teeth to be treated must demonstrate at least 4-millimeter pocket depths, bleeding on probing, with demonstrable radiographic evidence of bone loss (either vertical or horizontal) of the alveolar crest.
   
• Bone loss is considered to be a bone level that is greater 1.5mm apical to the CEJ (cementoenamel junction).
   
• Non-surgical periodontal and periodontal maintenance procedures will be disallowed with no patient responsibility when submitted on the same date of service as preventive prophylaxis procedures.