D7995 — Synthetic graft facial bones
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Key Coverage Criteria
- Asymmetries defined as the following:Anteroposterior, transverse or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry.
- Mandibular/Maxillary (orthognathic) surgery is consideredmedically necessaryto treat a significant functional impairment when the procedure can be reasonably expected to improve the functional impairment. Significant functional impairment includesanyoneof the following (I, II, III,orIV below):
- Dysphagiawhenallof the following criteria (A, B and C) are met:Symptoms related to difficulty chewing such as: choking due to incomplete mastication, or difficulty swallowing chewed solid food, or ability to chew only soft food or reliance on liquid food;andSymptoms must be documented in the medical record, must be significant and must persist for at least 4 months;andOther causes of swallowing or choking problems have been ruled out by history, physical exam, and appropriate diagnostic studies; [...]
- Symptoms related to difficulty chewing such as: choking due to incomplete mastication, or difficulty swallowing chewed solid food, or ability to chew only soft food or reliance on liquid food;and
- Symptoms must be documented in the medical record, must be significant and must persist for at least 4 months;and
- Other causes of swallowing or choking problems have been ruled out by history, physical exam, and appropriate diagnostic studies;or
3 Active Policies
ANTHEM-MED.00002 — MED.00002 Selected Sleep Testing Services
ANTHEM-CG-SURG-84 — CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery
REGENCE-SUR137 — Orthognathic Surgery
Related Codes
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