Extractions (D7111-D7250):

The extraction of asymptomatic teeth is not a benefit. The following conditions shall be considered symptomatic and shall be a benefit:

full bony impacted supernumerary teeth, mesiodens or teeth unerupted because of lack of alveolar ridge length,
teeth which are involved with a cyst, tumor or other neoplasm,
unerupted teeth which are distorting the normal alignment of erupted teeth or causing the resorption of the roots of other teeth,
the extraction of all remaining teeth in preparation for a full prosthesis,
malaligned teeth which cause intermittent gingival inflammation,
extraction of primary teeth required to minimize malocclusion or malalignment when there is adequate space to allow normal eruption of succedaneous teeth,
perceptible radiologic pathology that fails to elicit symptoms, extractions that are required to complete orthodontic dental services