K04.01 — Reversible pulpitis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Use of moderate to deep anesthesia services in conjunction with the delivery of dental services in the facility setting is consideredmedicallynecessarywhen the following criteria have been met (AandB):
- Extensive surgical procedures are required;and
- Submitted documentation (including narrative, radiographs, etc.) demonstrates that the individual has a condition, medical comorbidity, or current medical status that requires a facility setting, including, but not limited to the following:The individual is currently hospitalized and requires dental care during the hospital stay;orThe individual is a child under 6 years of age;orThe risk of intraoperative complications is elevated, as indicated by assignment of American Society of Anesthesiologi [...]
- The individual is currently hospitalized and requires dental care during the hospital stay;or
- The individual is a child under 6 years of age;or
- The risk of intraoperative complications is elevated, as indicated by assignment of American Society of Anesthesiologists (ASA) as class III or class IV;or
1 Active Policy
ANTHEM-CG-MED-41 — CG-MED-41 Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting
Related Codes
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