Prior Auth Required

21159 - Reconstruction midface, LeFort III (extra Pre-Service Review Required Medical Necessity Submit cephalometric, panoramic films

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Procedure / ServiceReconstruction midface, LeFort III (extra 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); with orthodontic treatment. Fax to Dental LeFort I Review @ 425-918-5956 21159 Reconstruction midface, LeFort III (extra Pre-Service Review Required Medical Necessity Submit cephalometric, panoramic films and intracranial) with forehead and photos, age and history of advancement (eg, mono bloc), requiring 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.