21116
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.79
Facility
$38.75
Non-Facility
$222.45
Key Coverage Criteria
- Surgical procedures areconsideredmedically necessaryfor the treatment of temporomandibular disorderswhen the following criteria are met (AandB):
- Temporomandibular joint internal derangement or other structural joint disorder is documented as evidenced by the following:Radiographic documentation of temporomandibular joint pathology(for example, arthritis, bone cyst, fracture, meniscal abnormality, or tumors);andFor individuals under the age of 18 years: documentation of completion of skeletal growth by either:Long bone x-ray;orSerial cephalometrics showing no change in facial bone relationships over the last 3- to 6- month period;and
- Radiographic documentation of temporomandibular joint pathology(for example, arthritis, bone cyst, fracture, meniscal abnormality, or tumors);and
- For individuals under the age of 18 years: documentation of completion of skeletal growth by either:Long bone x-ray;orSerial cephalometrics showing no change in facial bone relationships over the last 3- to 6- month period;and
- Long bone x-ray;or
- Serial cephalometrics showing no change in facial bone relationships over the last 3- to 6- month period;and
1 Active Policy
ANTHEM-GL-A051149 — CPT
Related Codes
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