Does 21100 require prior authorization?

No, 21100 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 21100?

Medicare facility rate: $332.34. Non-facility rate: $630.94. Work RVU: 4.61.

Verity

`21100`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

4.61

Facility

$332.34

Non-Facility

$630.94

Documentation Required

No explicit documentation requirements are stated in this excerpt.
No documentation requirements are specified in the provided excerpt.
No explicit documentation requirements are stated in the provided text.
Implied required documentation (not explicitly listed but necessary to demonstrate criteria): clinical measurements documenting the millimeter discrepancy (bilateral or unilateral), documentation of concomitant occlusal asymmetry when claiming asymmetry coverage, documentation of the etiology of skeletal-facial deformity (e.g., acquired defect, degenerative disease, genetic, neoplasm, trauma), and documentation that oral surgical splints are being used in conjunction with qualifying orthognathic surgery

Key Coverage Criteria

Orthognathic surgery when Humana-specific requirements (as may be described elsewhere in the full policy) are met.
Severe skeletal deformities where the severity necessitates surgical correction (often in combination with other rehabilitative services).
Acquired deformities, including post-traumatic or post-surgical deformities.
Deformities secondary to systemic diseases.
Procedures with the primary goal to improve form and function through correction of the underlying skeletal deformity.
Repositioning the affected areas (mentum, mandible and/or maxilla) to approximate normal alignment and structure.

1 Active Policy

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

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Inferred necessary documentation (not explicitly listed but typically required to support medical necessity): medical records documenting the diagnosis and severity of the skeletal deformity; imaging studies (e.g., cephalometric radiographs, CT) demonstrating mandibular/maxillary skeletal abnormality; documentation of congenital, acquired (post-traumatic or post-surgical), or systemic disease etiology; clinical notes describing functional impairments and goals for improvement of form and function; treatment plan outlining the proposed orthognathic surgical procedures and any planned rehabilitative services.

21100