Z46.4 — Encounter for fitting and adjustment of orthodontic device
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Upon review by Aetna's Oral and Maxillofacial Surgery (OMS) Unit, distraction osteogenesis may be considered medically necessary for correction of functional impairments accompanying other congenital craniofacial anomalies where it is determined that distraction osteogenesis can uniquely produce a degree of improvement unavailable with other standard techniques. (Documentation of OMS Unit review is implied.)
- Documentation that the patient's condition matches one of the listed congenital craniofacial skeletal deformities and that there is a functional impairment to be corrected (e.g., airway obstruction, severe mandibular deficiency >10 mm).
- When claiming coverage for indications such as hemifacial microsomia, documentation that the child has 'sufficient bone to allow for a corticotomy and/or osteotomy and placement of pins for external or internal distraction devices (i.e., Pruzansky Grade I and IIa type mandibular deformity)'.
Key Coverage Criteria
- ICD-10 diagnoses listed as covered when selection criteria are met: Q37.0 - Q37.9 (Cleft palate with cleft lip)
- ICD-10 diagnoses listed as covered when selection criteria are met: Q67.0 - Q67.4 (Congenital deformities of skull, face and jaw)
- ICD-10 diagnoses listed as covered when selection criteria are met: Q75.0 - Q75.9 (Congenital malformation of skull and face bones [includes hemifacial microstomia])
- ICD-10 diagnoses listed as covered when selection criteria are met: Q87.0 (Congenital malformation syndromes predominantly affecting facial appearance)
- Distraction osteogenesis (distraction histogenesis) medically necessary for the correction of functional impairments accompanying the following congenital craniofacial skeletal deformities:
- Cleft lip and palate;
1 Active Policy
AETNA-CPB-0549 — Distraction Osteogenesis for Craniofacial Defects
Related Codes
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