K04.6 — Periapical abscess with sinus
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- None specified in this policy. (The CPB does not list required medical records, test results, or other documentation for coverage because the services are considered experimental/investigational and not covered.)
Key Coverage Criteria
- Aetna considers the use of devices to image the jawbones to diagnose NICO or NICO-type conditions experimental and investigational.
- None. The policy states that surgery, other therapies, bone graft replacement, and devices to image the jawbones (including ultrasonograph bone densitometer) for diagnosis or treatment of neuralgia inducing cavitational osteonecrosis (NICO) or NICO-type conditions are considered experimental and investigational and therefore are not covered.
1 Active Policy
AETNA-CPB-0642 — Neuralgia Inducing Cavitational Osteonecrosis (NICO) and Ultrasonograph Bone Densitometer to Detect NICO
Related Codes
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