D9940
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- None specified in this policy bulletin.
Key Coverage Criteria
- None. Aetna considers intra-oral appliances (e.g., the Nociceptive Trigeminal Inhibition-Tension Suppression System) experimental and investigational for the treatment of headaches and trigeminal neuralgia because the effectiveness of this approach for these indications has not been established.
- 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
2 Active Policies
AETNA-CPB-0688 — Intra-oral Appliances for Headaches and Trigeminal Neuralgia
ANTHEM-GL-A051149 — CPT
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.