Does 21047 require prior authorization?

No, 21047 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 21047?

Medicare facility rate: $1076.51. Non-facility rate: $1076.51. Work RVU: 19.57.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

19.57

Facility

$1076.51

Non-Facility

$1076.51

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).
Review and document the member's benefit contract or Summary Plan Description (SPD) showing coverage, exclusions, and any dollar or duration limits.

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.
Surgical procedures on teeth suspected to cause orofacial pain (including NICO) only when an orofacial pain specialist has confirmed the diagnosis.
Diagnosis, treatment and follow-up of orofacial pain conditions should be performed by or referred to orofacial pain specialists.

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)

SUR705.028 — Neuralgia Inducing Cavitational Osteonecrosis (NICO)

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