Does 41874 require prior authorization?

Yes, 41874 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 41874?

Medicare facility rate: $225.46. Non-facility rate: $390.46. Work RVU: 3.11.

HCPCS/CPT

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Work RVU

3.11

Facility

$225.46

Non-Facility

$390.46

Evidence that benefits for alveoloplasty are available under the member's specific benefit plan document (Group Service Agreement, EOC, Certificate of Coverage, SPD, etc.)
For congenital/developmental defect indication: documentation of the congenital defect or developmental malformation and that it interferes with function
For accidental injury indication: documentation of the accidental injury, date of injury, evidence that the teeth were 'sound' prior to injury, and that the injury/loss occurred after the member's date of coverage (and within 12 months of tooth loss or as specified by the plan)
For oral cancer indication: documentation of the oral cancer diagnosis and that loss of natural teeth occurred while the member was covered, and documentation that replacement will occur within 24 months of tooth loss (or as specified by plan)

Alveoloplasty (CPT 41874) is considered medically necessary when ANY of the following criteria are met:
in an individual with a congenital defect or developmental malformation which interferes with function
following an accidental injury to sound natural teeth that occurs after the date of coverage within 12 months of the loss of natural teeth, or as specified in the benefit plan language (Note: Chewing injuries are not considered accidental injuries)
loss of natural teeth due to oral cancer which interferes with function. In order to be eligible, the loss of teeth must have occurred while covered under the plan and replacement must occur within 24 months of the loss of natural teeth, or as specified in the benefit plan language
when provided in preparation for, or in the course of, treatment (i.e., radiation, chemotherapy) for head and neck cancer

CIGNA-0586 — Alveoloplasty - (0586)

REGENCE-AH35 — Administrative Guidelines to Determine Dental vs Medical Services

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