S21.95XS — Open bite of unspecified part of thorax, sequela
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Cyanide poisoning;or
- Decompression sickness;or
- Systemic hyperbaric oxygen pressurization is consideredmedically necessaryin the treatment of any of the following conditions when performed in accordance with Undersea and Hyperbaric Medical Society (UHMS) guidelines:
- Acute peripheral arterial insufficiency;or
- Acute thermal burns: deep second degree or third degree in nature;or
- Acute traumatic ischemia;or
1 Active Policy
ANTHEM-CG-MED-73 — CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
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