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Coverage criteria policies

Dental services – oral surgery

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Oral surgery for the treatment of a medical condition does not require prior authorization.


Oral surgery is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Coverage is generally limited to the treatment of the following oral medical conditions:

  1. Infections and abscesses of the mouth which are not of dental origin.
  2. Perioral diseases or lesions (occurring in or around the mouth).
  3. Lesions of the hard and/or soft tissue, such as a neoplasm (abnormal growth) in the jaw or inflammation of the cheek. This does not include lesions of the teeth or lesions of the supporting bone associated with a dental condition.
  4. Cysts within the mouth that appear cancerous or pre-cancerous (a condition that may become cancer)

Indications that are not covered

Services not eligible for coverage include but are not limited to:

  1. Tooth removal (extraction)due to dental, periodontal (gum) or occlusal (bite) diseases or disorders
  2. Removal of extra teeth, which may be referred to as supernumerary or mesiodens
  3. Treatment of the teeth or structures supporting the teeth
  4. Treatment of periodontal (gum) disease
  5. Treatment of dental cysts (cysts which contain teeth or appear on exam to arise out of tissues that create teeth) or benign (non-cancerous) cysts which interfere with eruption of teeth
  6. Treatment necessary for placement of dentures, such as jaw reconstruction due to bone loss
  7. Treatment described as dental restoration, reconstruction or rehabilitation to correct defects such as missing teeth, missing parts of teeth or missing soft or hard structures of the jaw and palate (examples include but are not limited to crowns, bridges, veneers, or surgically placed dental implants). This includes services associated with placement of dental implants, including but not limited to bone grafting or sinus lifts.


Oral Surgery is the treatment of diseases within the mouth (intraoral) or around the mouth (perioral). These are services related to treatment of medical conditions requiring oral surgery, such as treatment of oral neoplasm, non-dental cysts, fracture of the jaws, trauma of the mouth and jaws, and any other oral surgery procedures provided as medically necessary dental services.


This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 01/01/1994 - Date of origin
  • 01/01/1994 - Effective date
Review date
  • 03/2018

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