Prior Auth Required

21490 - Open treatment of temporomandibular Pre-Service Review Required Medical Necessity Submit diagnosis, prognosis and chart

This procedure appears on the selected insurer prior authorization source.

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Prior authorizationPrior Auth Required
Procedure / ServiceOpen treatment of temporomandibular Pre-Service Review Required Medical Necessity Submit diagnosis, prognosis and chart
Procedure / Service Description

(eg, for treatment of benign masseteric medical necessity, procedure report. - initial or subsequent Fax to Dental Review @ 425-918-5956 21490 Open treatment of temporomandibular Pre-Service Review Required Medical Necessity Submit diagnosis, prognosis and chart dislocation notes including history of non-invasive or non-surgical attempts to treat the TMJ.

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.