Does S03.00XA require prior authorization?

No, S03.00XA does not require prior authorization (high confidence). Covered without prior authorization.

`S03.00XA`, Dislocation of jaw, unspecified side, initial encounter

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Billing and coding guidance in this policy complements and references Local Coverage Determination L34425; claims should be supported per the documentation requirements specified in LCD L34425.

No specific clinical indications are listed in this billing/coding guidance; coverage determinations for MRI of the head and neck follow Local Coverage Determination L34425.
Surgical procedures areconsideredmedically necessaryfor the treatment of temporomandibular disorderswhen the following criteria are met (AandB):
Temporomandibular joint internal derangement or other structural joint disorder is documented as evidenced by the following:Radiographic documentation of temporomandibular joint pathology(for example, arthritis, bone cyst, fracture, meniscal abnormality, or tumors);andFor individuals under the age of 18 years: documentation of completion of skeletal growth by either:Long bone x-ray;orSerial cephalometrics showing no change in facial bone relationships over the last 3- to 6- month period;and
Radiographic documentation of temporomandibular joint pathology(for example, arthritis, bone cyst, fracture, meniscal abnormality, or tumors);and
For individuals under the age of 18 years: documentation of completion of skeletal growth by either:Long bone x-ray;orSerial cephalometrics showing no change in facial bone relationships over the last 3- to 6- month period;and
Long bone x-ray;or

ANTHEM-GL-A051149, CPT

ANTHEM-CG-MED-28, Iontophoresis

A56729, Billing and Coding: Magnetic Resonance Imaging of the Head and Neck

Ask Backwork about documentation requirements, denial risks, or coverage in your state.