21030
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
4.79
Facility
$336.68
Non-Facility
$475.96
Documentation Required
- 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).
Key Coverage Criteria
- 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.
6 Active Policies
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)
Related Codes
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