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Third Molar Extraction Criteria for HKD Enrollees

The Healthy Kids Dental (HKD) program does not cover prophylactic removal of pathology-free (asymptomatic) third molars. Surgical removal of third molars must be substantiated by evidence of pathology. Claims for extraction of one of more third molars for a HKD enrollee must include a short narrative in the “Remarks” section of the claim form that describes the specific pathology that indicated extraction.

Evidence of pathology includes the following conditions:

  • Unrestorable caries
  • Fracture
  • Caries in the adjacent second molar that cannot satisfactorily be treated without the removal of the third molar
  • Non-treatable pulpal and/or periapical pathology
  • Unmanageable periodontal disease in a second molar that was caused or exacerbated by the position of the adjacent third molar
  • Second or subsequent episodes of pericoronitis (unless the first episode is particularly severe) that cannot be safely controlled through the use of antibiotics, irrigation, or other topical treatment
  • Cellulitis, abscess, or osteomyelitis
  • Internal/external resorption of the third molar or adjacent teeth
  • Follicular disease, including cyst/tumor
  • Tooth/teeth impeding orthognathic surgery, reconstructive surgery, trauma surgery, or other jaw surgery
  • Involvement in a tumor or within the field of tumor resection
  • Medical condition(s) in which the risks associated with third molar retention outweigh the potential complications associated with extraction, such as prior to radiotherapy, cardiac surgery, or organ transplant

Other conditions will be evaluated on a case-by-case basis

The following conditions do not indicate medical necessity:

(Note: Prophylactic removal of pathology-free (asymptomatic) third molars is not a covered benefit. Adjunctive service, such as general anesthesia or deep sedation, administered in conjunction with non-covered extractions is not covered.)

  • Orthodontia-related extraction(s)
  • Non-symptomatic impaction
  • Pain and/or swelling unless supported by documentation of qualifying pathology

HKD information for dentists:

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