Alveoloplasty - (0586)

Cigna covers alveoloplasty (CPT 41874) only for specific indications — congenital/developmental malformations that impair function, accidental injury to previously sound teeth occurring after plan coverage within 12 months (chewing injuries excluded), tooth loss from oral cancer if the loss occurred while covered and replacement is within 24 months, or when done in preparation for or during head & neck cancer treatment — and excludes all other indications (e.g., wisdom tooth extraction). Coverage requires the member’s plan to include oral surgery benefits and submission of detailed documentation (plan benefit verification, diagnosis, dates, proof teeth were sound prior to injury, cancer diagnosis/timing or treatment intent, operative/clinical notes) and billing with CPT 41874 and appropriate diagnosis codes; procedures contraindicated because removal would harm vital structures or are not clinically necessary are not covered.

"Alveoloplasty (CPT 41874) is considered medically necessary when ANY of the following criteria are met:"