Is the extraction covered or not covered?

by User Not Found | Aug 31, 2017

3rd molar extractions can be tricky.  Don’t let confusion around the OHP benefit make them any harder.  Below are OHP rules that determine if the extraction is covered or not covered.

Is the 3rd molar erupted?

YES: There needs to be clinical justification for the extraction.  Follow the same diagnosis and treatment plan criteria as any other tooth to be extracted. 

NO: Impacted 3rd molar extractions have a few more rules.  Each individual impacted 3rd molar referred requires documentation.

The criterion for impacted 3rd molar extraction is the presence of:

  • an acute infection or abscess,
  • severe tooth pain, or
  • unusual swelling of the face or gums

 

Now that we’ve covered erupted vs impacted 3rd molars, let’s check out your “wisdom” on extractions.

TRUE or FALSE

  1. Routine extraction of 3rd molars is covered.

    FALSE  Clinical justification for extraction is required in the patient’s chart notes.

  2. Documentation is required for each individual 3rd molar referred for extraction.

    TRUE  Tooth number, diagnosis, and symptoms, such as pain severity, for each tooth referred is required.

  3. Erupted or impacted: Documentation needs to include the clinical justification for extraction.

    TRUE  It does not matter if the 3rd molar is erupted or impacted. 

  4. Mild pain associated with normal eruption of impacted 3rd molars qualifies for extraction.

    FALSE  Some discomfort is expected and normal with eruption. Severe pain, not mild pain, is grounds for extraction.  

  5. Do not send CareOregon Dental clinical documentation if you extract a 3rd molar in your clinic.

    TRUE  We do not need additional documentation if you provide these services in-house.

  6. The referral form alone is sufficient clinical documentation for the extraction referral.

    FALSE  The referral must include appropriate clinical notes such as the progress note or tooth charting with the treatment plan.

  7. OHP covers the removal of impacted teeth due to acute infection or abscess, severe tooth pain, or unusual swelling of the face or gums. 

    TRUE  To find the extraction rules, download the most current  Administrative Rulebook from the OHP Dental Services program webpage.

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