Oral Surgery: Non-Pathologic Excisional Procedures
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UnitedHealthcare Dental Coverage Guideline
Effective 10/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
UnitedHealthcare
®
Dental
Coverage Guideline
Oral Surgery: Non-Pathologic Excisional Procedures
Guideline Number: DCG029.10
Effective Date: October 1, 2023
Instructions for Use
Table of Contents Page
Coverage Rationale ....................................................................... 1
Definitions ...................................................................................... 2
Applicable Codes .......................................................................... 2
Description of Services ................................................................. 3
References ..................................................................................... 3
Guideline History/Revision Information ....................................... 3
Instructions for Use ....................................................................... 4
Coverage Rationale
Frenulectomy/Frenuloplasty
Frenulectomy and Frenuloplasty are indicated for the following:
When attachment of the Frenum is coronal to the mucogingival junction, within the free gingiva, or in the papilla causing a
diastema, gingival recession, or stripping
When the position attachment of the Frenum is interfering with proper oral hygiene
Prior to the construction of a removable denture replacing teeth in the area of aberrant frenal attachment
When there is a functional disturbance, including, but not limited to mastication, swallowing, and speech
For Ankyloglossia or papillary penetrating attachment of maxillary labial Frenum in newborns when there is interference
with feeding
Excision of Hyperplastic Tissue and Surgical Reduction of Fibrous Tuberosity
Excision of Hyperplastic tissue and surgical reduction of a fibrous Tuberosity is indicated when the presence of excess
tissue interferes with the fit of a partial or complete denture (existing or new).
Excision of Pericoronal Gingiva
Excision of pericoronal gingiva is indicated for the following:
For recurrent infections of the operculum around impacted or partially erupted lower third molars
When an erupted maxillary third molar is traumatizing soft tissue around opposing tooth
When the presence interferes with the fit of a partial or complete denture
Transseptal Fiberotomy/Supra Crestal Fiberotomy, By Report
Transseptal fiberotomy/supra crestal fiberotomy is indicated to reduce rotational relapse of individual teeth following
orthodontic treatment.
Removal of Lateral Exostosis (Maxilla or Mandible), Torus Palatinus and Torus Mandibularis
Removal of lateral Exostoses, Torus Palatinus and Torus Mandibularis is indicated for the following:
If a partial or complete denture cannot be adapted successfully
When causing soft tissue trauma with existing removable appliances
Related Dental Policies
• Fixed Prosthodontics
• Medically Necessary Orthodontic Treatment
• Oral Surgery: Alveoloplasty and Vestibuloplasty
• Oral Surgery: Miscellaneous Procedures
•
Removable Prosthodontics
Oral Surgery: Non-Pathologic Excisional Procedures
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For unusually large protuberances that are prone to recurrent traumatic injury
When there is a functional disturbance, including, but not limited to mastication, swallowing and speech
Bony excisional procedures are not indicated for patients with unmanaged medical conditions that result in excessive or
uncontrolled bleeding, reduced resistance to infection, or poor healing response.
Definitions
Ankyloglossia: Partial or complete fusion of the tongue with the floor of the mouth or the lingual gingiva due to an abnormally
short, mid-line lingual Frenulum, resulting in restricted tongue movement (also known as tongue-tie). (AAP)
Exostosis/Exostoses: A benign, bony growth projecting outward from the surface of a bone. (AAP)
Frenum/Frenulum: A fold of mucous membrane tissue that attaches the lips and cheeks to the alveolar mucosa (and/or
gingiva) and underlying periosteum. (AAP)
The Placek’s Classification of Labial Frenal Attachments (Devishree et. al):
Mucosal: When the frenal fibres are attached up to the mucogingival junction
Gingival: When the fibres are inserted within the attached gingiva
Papillary: When the fibres are extending into the interdental papilla
Papilla Penetrating: When the frenal fibres cross the alveolar process and extend up to the palatine papilla
Hyperplastic: The increase in the size of a structure due to an increase in the number of cells. (AAP)
Torus Palatinus: A bony protuberance occurring at the midline of the hard palate. (AAP)
Torus Mandibularis: A bony exostosis on the lingual aspect of the mandible, generally in the premolarmolar region; commonly
bilateral. (AAP)
Tuberosity: An osseous projection or protuberance. (AAP)
Applicable Codes
The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive.
Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health
service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws
that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or
guarantee claim payment. Other Policies and Guidelines may apply.
CDT Code
Description
D7291
Transseptal fiberotomy/supra crestal fiberotomy, by report
D7471
Removal of lateral exostosis (maxilla or mandible)
D7472
Removal of torus palatinus
D7473
Removal of torus mandibularis
D7961
Buccal / labial frenectomy (frenulectomy)
D7962
Lingual frenectomy (frenulectomy)
D7963
Frenuloplasty
D7970
Excision of hyperplastic tissue – per arch
D7971
Excision of pericoronal gingiva
D7972
Surgical reduction of fibrous tuberosity
D7999
Unspecified oral surgery procedure, by report
CDT
®
is a registered trademark of the American Dental Association
Oral Surgery: Non-Pathologic Excisional Procedures
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CPT Code
Description
21031
Excision of torus mandibularis
21032
Excision of maxillary torus palatinus
40806
Incision of labial frenum (frenotomy)
40819
Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy)
41010
Incision of lingual frenum (frenotomy)
41115
Excision of lingual frenum (frenectomy)
41520
Frenoplasty (surgical revision of frenum, e.g., with Z-plasty)
41821
Operculectomy, excision pericoronal tissues
41822
Excision of fibrous tuberosities, dentoalveolar structures
41828
Excision of hyperplastic alveolar mucosa, each quadrant (specify)
CPT
®
is a registered trademark of the American Medical Association
Description of Services
Oral surgery excisional procedures involve the removal and/or alteration of hard and soft oral tissues to achieve normal
physiologic function or allow the proper fit of removable appliances.
Pursuant to CA AB2585: While not common in dentistry, nonpharmacological pain management strategies should be
encouraged if appropriate.
References
Akylacin S, Kapadia H, English J. Mosby’s Orthodontic Review, 2nd ed. St. Louis: Mosby c2015. Chapter 23, Retention and
Relapse in Orthodontics; p. 297.
American Academy of Pediatric Dentistry Guideline on Management Considerations for Pediatric Oral Surgery and Oral
Pathology. Adopted 2005. Revised 2020.
American Academy of Peridontology (AAP) Glossary of Periodontal Terms.
American Dental Association (ADA) CDT Codebook 2023.
American Dental Association Glossary of Clinical and Administrative Terms.
Carr A, Brown D. McCracken’s Removable Partial Prosthodontics, 13th ed. St. Louis: Mosby c2016. Chapter 14, Preparation of
the Mouth for Removable Partial Dentures; p. 190-191.
Devishree, Gujjari SK, Shubhashini PV. Frenectomy: a review with the reports of surgical techniques. J Clin Diagn Res. 2012
Nov; 6(9):1587-92.
Ness G. Atlas of Oral and Maxillofacial Surgery, 1st ed. St. Louis: Mosby c2016. Chapter 14, Palatal and Lingual Torus Removal;
p.120-26.
Shenoy S, Boaz K, Caroline Rodriguez Pena, et al. Textbook of Oral Medicine, Oral Diagnosis and Oral Radiology, 2nd ed.
India: Mosby c2013.Section II- Oral and Maxillofacial Disturbances, Chapter 2, Developmental Disturbances; p.19-21.
Takei E. Scheyer T, Azzi R, et al. Newman and Carranza’s Clinical Periodontology, 13th ed. St. Louis: Mosby c2019. Chapter 65,
Periodontal Plastic and Esthetic Surgery; p. 660-663.
Guideline History/Revision Information
Date
Summary of Changes
02/01/2024
Template Update
Updated
Instructions for Use
to clarify this policy applies to both Commercial and Medicare
Advantage plans
Oral Surgery: Non-Pathologic Excisional Procedures
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UnitedHealthcare Dental Coverage Guideline
Effective 10/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
Date
Summary of Changes
10/01/2023
Coverage Rationale
Removed content addressing coverage limitations and exclusions
Supporting Information
Updated
References
section to reflect the most current information
Archived previous policy version DCG029.09
Instructions for Use
This Dental Coverage Guideline provides assistance in interpreting UnitedHealthcare standard and Medicare Advantage dental
plans. When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member
specific benefit plan may differ from the standard dental plan. In the event of a conflict, the member specific benefit plan
document governs. Before using this guideline, please check the member specific benefit plan document and any applicable
federal or state mandates. UnitedHealthcare reserves the right to modify its Policies and Guidelines as necessary. This Dental
Coverage Guideline is provided for informational purposes. It does not constitute medical advice.
