Prior Auth Required

21155 - Reconstruction midface, LeFort III Pre-Service Review Required Medical Necessity Submit cephalometric, panoramic films

This procedure appears on the selected insurer prior authorization source.

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Procedure / ServiceReconstruction midface, LeFort III Pre-Service Review Required Medical Necessity Submit cephalometric, panoramic films
Procedure / Service Description

Code Description Plan Review Requirement Reviewed For Records Request - grafts (includes obtaining autografts); orthodontic treatment. Fax to Dental without LeFort I Review @ 425-918-5956 21155 Reconstruction midface, LeFort III Pre-Service Review Required Medical Necessity Submit cephalometric, panoramic films (extracranial), any type, requiring bone and photos, age and history of grafts (includes obtaining autografts); with orthodontic treatment. Fax to Dental

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.