Does 21026 require prior authorization?

No, 21026 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 21026?

Medicare facility rate: $413.50. Non-facility rate: $576.17. Work RVU: 5.56.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

5.56

Facility

$413.50

Non-Facility

$576.17

None specified in this policy. (The CPB does not list required medical records, test results, or other documentation for coverage because the services are considered experimental/investigational and not covered.)
Documentation of diagnosis confirmation by an orofacial pain specialist (specialist consultation notes).
Treatment plan and follow-up documentation showing care was performed or overseen by an orofacial pain specialist.
Documentation demonstrating that extraction was not recommended solely for prevention of NICO (if applicable).

Aetna considers the use of devices to image the jawbones to diagnose NICO or NICO-type conditions experimental and investigational.
None. The policy states that surgery, other therapies, bone graft replacement, and devices to image the jawbones (including ultrasonograph bone densitometer) for diagnosis or treatment of neuralgia inducing cavitational osteonecrosis (NICO) or NICO-type conditions are considered experimental and investigational and therefore are not covered.
Tooth extraction followed by periapical curettage may be offered to attempt to alleviate chronic pain associated with previously endodontically treated teeth.
Odontalgia (tooth pain)
Myofascial pain
No documented indications supporting surgical intervention specifically to treat suspected NICO lesions.

AETNA-CPB-0642 — Neuralgia Inducing Cavitational Osteonecrosis (NICO) and Ultrasonograph Bone Densitometer to Detect NICO

BCBSIL-SUR705.028 — Neuralgia Inducing Cavitational Osteonecrosis (NICO)

BCBSMT-SUR705.028 — Neuralgia Inducing Cavitational Osteonecrosis (NICO)

BCBSNM-SUR705.028 — Neuralgia Inducing Cavitational Osteonecrosis (NICO)

BCBSOK-SUR705.028 — Neuralgia Inducing Cavitational Osteonecrosis (NICO)

Ask Verity about documentation requirements, denial risks, or coverage in your state.