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ICD-10-CM K04.01, Reversible pulpitis | No Prior Auth

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`K04.01`, Reversible pulpitis

ICD-10-CM

Prior Authorization

No Prior Auth Required

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, Moderate to Deep Anesthesia Services for Dental Surgery in the Facility Setting

Related Codes

41899(1 policies)99143(1 policies)99145(1 policies)99148(1 policies)99150(1 policies)99151(1 policies)99152(1 policies)00170(1 policies)

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