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Policy No:  50

Originally Created: 03/01/1997

Section: Oral and Maxillofacial Surgery

Last Reviewed:  01/01/2019

Last Revised:  01/01/2018

Approved: 01/01/2018

Effective:  01/01/2018

Description

Excision of benign lesion

  • up to 1.25 cm (D7410)
  • greater than 1.25 cm (D7411)
  • complicated (D7412)

Excision of malignant lesion

  • up to 1.25 cm (D7413)
  • greater than 1.25 cm (D7414)
  • complicated (D7415): requires extensive undermining with advancement or rotational flap closure.

Excision of malignant tumor

  • lesion diameter up to 1.25 cm (D7440)
  • lesion diameter greater than 1.25cm (D7441)

Removal of benign odontogenic cyst or tumor

  • lesion diameter up to 1.25 cm (D7450)
  • lesion diameter greater than 1.25 cm (D7451)

Removal of benign nonodontogenic cyst or tumor

  • lesion diameter up to 1.25 cm (D7460)
  • lesion diameter greater than 1.25 cm (D7461)

Destruction of lesion(s) by physical or chemical method, by report (D7465)

  • Examples include using cryo, laser or electro surgery.

Policy/criteria

Procedure is in accordance with generally accepted standards of dental practice.

Administrative guidelines

Process to contract benefits.

Procedures may be subject to review by the dental consultant.

Procedures D7440 and D7441 – considered medical as a malignant condition is systemic and therefore considered medical. D7410 - D7412 process dental. Process to medical benefit.  Submit on medical claim form with applicable medical CPT code and diagnosis code.

Codes

CDT - D7000-D7999 - see above

Disclaimer

Your use of this Dental Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Dental Policy Disclaimer.