Medical Policy
Effective Date:01/01/2006 Title:Dental Care - Impacted Teeth
Revision Date:01/01/2013 Document:BI207:00
CPT Code(s):D7220, D7230, D7240, D7241, D7250, D7251, D7260, D7261, D7270, D7272, D7280
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

QualChoice does not cover costs associated with the extraction of impacted teeth, other than as covered in BI432.
Medical Statement

QualChoice medical coverage does not cover costs associated with the extraction of impacted teeth, no matter how badly impacted they are or from what cause.

 

Codes Used In This BI:

D7220

Impact tooth remov soft tiss

D7230

Impact tooth remov part bony

D7240

Impact tooth remov comp bony

D7241

Impact tooth rem bony w/comp

D7250

Tooth root removal

D7251

Coronectomy

D7260

Oral antral fistula closure

D7261

Primary closure sinus perf

D7270

Tooth reimplantation

D7272

Tooth transplantation

D7280

Exposure impact tooth orthod
Limits
Intentially left empty
Reference
Intentially left empty
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.