K04.4 — Acute apical periodontitis of pulpal origin
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical trial/reporting deficiencies noted: many studies lacked standardized reporting of laser parameters, allocation concealment, blinding, withdrawals, and treatment protocols — implying that documentation of laser parameters (wavelength, power, J/cm2, duration, frequency) would be important though not formally required in this text.
- No documentation requirements, billing criteria, ICD-10/CPT codes, or explicit medical necessity documentation instructions are specified in this document.
- Clinical notes supporting medical necessity and that the patient meets any applicable selection criteria (the CPB references 'selection criteria' for coverage of CPT 0552T but the selection criteria text is not included in this chunk).
- Documentation of the specific laser therapy modality and parameters used (device, wavelength, dosing) and treatment dates to support billing of CPT 0552T when covered.
Key Coverage Criteria
- Peri-implant mucositis (p-iM)
- Aggressive periodontitis (as adjunct to scaling and root planing [SRP])
- Skin burns (experimental models; LLLT to accelerate healing)
- Tendon repair (animal models; LLLT often studied alone or combined with adipose-derived mesenchymal stem cells)
- Brain photobiomodulation / transcranial LLLT for traumatic brain injury (TBI), Alzheimer disease (AD), depression, Parkinson disease (PD), stroke, and cognitive enhancement
- Fibromyalgia (LLLT evaluated as adjuvant to exercise or vs placebo)
1 Active Policy
AETNA-CPB-0363 — Cold Laser and High-Power Laser Therapies
Related Codes
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