E1701 — Replacement cushions for jaw motion rehabilitation system, pkg. of 6
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled 'Medical Records Documentation Used for Reviews.'
- When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan; in the event of a conflict, the member specific benefit plan document governs.
- For TMJ surgical procedures: 'For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures' (Arthroscopy, Discectomy, Reconstruction) and 'InterQual® Client Defined, CP: Procedures, Arthroplasty, Temporomandibular Joint (TMJ) (Custom) - UHG' — documentation to meet InterQual criteria is required
Key Coverage Criteria
- Treatment of Temporomandibular Joint (TMJ) disorders
- The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Arthrocentesis
- The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Intra-articular injections of corticosteroids
- The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Trigger point injections
- The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Physical therapy
- The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Occlusal splint (stabilization and repositioning splints)
5 Active Policies
AETNA-CPB-0412 — Jaw Motion Rehabilitation Systems
ANTHEM-GL-A051149 — CPT
UHC-POL-temporomandibular-joint-disorders — Treatment of Temporomandibular Joint Disorders
UMR-POL-UMR-temporomandibular-joint-disorders — Treatment of Temporomandibular Joint Disorders
SUREST-POL-SUREST-temporomandibular-joint-disorders
Related Codes
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