Prior Auth Required

21089 - Unlisted maxillofacial prosthetic procedure Pre-Service Review Required Medical Necessity Submit chart notes including type of

This procedure appears on the selected insurer prior authorization source.

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Prior authorizationPrior Auth Required
Procedure / ServiceUnlisted maxillofacial prosthetic procedure Pre-Service Review Required Medical Necessity Submit chart notes including type of
Procedure / Service Description

documentation of medical necessity and - and copy of diagnostic sleep studies. Fax to Dental Review @ 425-918-5956. 21089 Unlisted maxillofacial prosthetic procedure Pre-Service Review Required Medical Necessity Submit chart notes including type of appliance, history of re-occurring TMJ and copy of diagnostic sleep studies. Fax

Likely documents
  • Confirm benefit details
  • Submit clinical notes if requested by the plan
Next actions
  • Confirm the current plan policy before submission.
  • Use the insurer authorization workflow for this listed code.