Does 21085 require prior authorization?

No, 21085 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 21085?

Medicare facility rate: $429.87. Non-facility rate: $710.10. Work RVU: 8.77.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

8.77

Facility

$429.87

Non-Facility

$710.10

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled 'Medical Records Documentation Used for Reviews.'
When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan; in the event of a conflict, the member specific benefit plan document governs.
For TMJ surgical procedures: 'For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures' (Arthroscopy, Discectomy, Reconstruction) and 'InterQual® Client Defined, CP: Procedures, Arthroplasty, Temporomandibular Joint (TMJ) (Custom) - UHG' — documentation to meet InterQual criteria is required

Treatment of Temporomandibular Joint (TMJ) disorders
The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Arthrocentesis
The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Intra-articular injections of corticosteroids
The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Trigger point injections
The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Physical therapy
The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Occlusal splint (stabilization and repositioning splints)

UHC-POL-temporomandibular-joint-disorders — Treatment of Temporomandibular Joint Disorders

UMR-POL-UMR-temporomandibular-joint-disorders — Treatment of Temporomandibular Joint Disorders

SUREST-POL-SUREST-temporomandibular-joint-disorders — Treatment of Temporomandibular Joint Disorders

HUMANA-ORTHOGNATHIC-SURGERY-MA — Orthognathic Surgery - Medicare Advantage

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