21049
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
18.84
Facility
$1021.07
Non-Facility
$1021.07
Documentation Required
- 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.
Key Coverage Criteria
- 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.
5 Active Policies
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)
Related Codes
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