Anthem Blue Cross and Blue Shield Virginia policy
CG-SURG-09 Temporomandibular Disorders
CG-SURG-09 Temporomandibular Disorders is a public Anthem Blue Cross and Blue Shield Virginia policy (policy CG-SURG-09). It lists 21 CPT or HCPCS codes, 17 of them on the Anthem Blue Cross and Blue Shield Virginia prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- CG-SURG-09
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross and Blue Shield Virginia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Virginia policies |
|---|---|---|---|
| 20605 | On the list | Arthrocentesis, Aspiration &/Or Injection; Intermediate Joint/Bursa | Policies naming 20605 |
| 20606 | On the list | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound gu | Policies naming 20606 |
| 21010 | On the list | Arthrotomy, Temporomandibular Joint | Policies naming 21010 |
| 21050 | On the list | Condylectomy, Temporomandibular Joint (Sep Proc) | Policies naming 21050 |
| 21060 | On the list | Meniscectomy, Partial/Complete, Temporomandibular Joint (Sep Proc) | Policies naming 21060 |
| 21073 | On the list | Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitor | Policies naming 21073 |
| 21110 | On the list | Application, Interdental Fixation Device, Non-Fx/Dislocation, W/Removal | Policies naming 21110 |
| 21116 | On the list | Injection Proc, Temporomandibular Joint Arthrography | Policies naming 21116 |
| 21210 | On the list | Graft, Bone; Nasal, Maxillary/Malar Areas (Includes Obtaining Graft) | Policies naming 21210 |
| 21240 | On the list | Arthroplasty, Temporomandibular Joint, W/Wo Autograft (Includes Obtaining Graft) | Policies naming 21240 |
| 21242 | On the list | Arthroplasty, Temporomandibular Joint, W/Allograft | Policies naming 21242 |
| 21243 | On the list | Arthroplasty, Temporomandibular Joint, W/Prosthetic Joint Replacement | Policies naming 21243 |
| 29800 | On the list | Arthroscopy, Temporomandibular Joint, Dx W/Wo Synovial Bx (Sep Proc) | Policies naming 29800 |
| 29804 | On the list | Arthroscopy, Temporomandibular Joint, Surgical | Policies naming 29804 |
| D7899 | Not listed | Policies naming D7899 | |
| D9950 | On the list | occlusion analysis - mounted case | Policies naming D9950 |
| D9951 | On the list | occlusal adjustment - limited | Policies naming D9951 |
| D9952 | On the list | occlusal adjustment - complete | Policies naming D9952 |
| E1700 | Not listed | Policies naming E1700 | |
| E1701 | Not listed | Policies naming E1701 | |
| E1702 | Not listed | Policies naming E1702 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list