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Medical PolicyHead and Neck Imaging CPT, HCPCS and Diagnoses CodesPolicy Number: 934BCBSA Reference Number: N/ANCD/LCD: N/ARelated Policies Medicare Advantage: Advanced Imaging/Radiology and Sleep Disorder Management Clinicaland Utilization Guidance Redirect, #923Advanced Imaging/Radiology CPT and HCPCS Codes, #900Advanced Imaging/Radiology, #968Oncologic Imaging CPT, HCPCS and Diagnoses Codes, #929Abdomen and Pelvic Imaging CPT, HCPCS and Diagnoses Codes, #930Brain Imaging CPT, HCPCS and Diagnoses Codes, #931Chest Imaging CPT, HCPCS and Diagnoses Codes, #932Extremity Imaging CPT, HCPCS and Diagnoses Codes, #933Spine Imaging CPT, HCPCS and Diagnoses Codes, #935Vascular Imaging CPT, HCPCS and Diagnoses Codes, #936Table of ContentsCommercial Products . 1Medicare Advantage Products . 2CPT Codes / HCPCS Codes / ICD Codes . 2CPT Codes: 70336 MRI of Temporomandibular Joint(s) . 2CPT Codes: 70486, 70487, 70488 CT of maxillofacial area . 12CPT Codes: 70540, 70542, 70543 MRI orbit, face and neck . 27CPT Codes: 70490, 70491, 70492 CT soft tissue neck . 97CPT Codes: 70450, 70460, 70470 CT head/brain . 106CPT codes: 70480, 70481, 70482 CT of orbit, sella or posterior fossa and outer, middle or inner ear . 224Policy History . 332Disclaimer:. 332Commercial ProductsThe following CPT and HCPCS codes are in-scope under the AIM Advanced Imaging/RadiologyManagement Program for Commercial Managed Care (HMO and POS) and Commercial PPO and EPO.1
For medical necessity criteria, see AIM Clinical Appropriateness Guidelines for AdvancedImaging/Radiology.Medicare Advantage ProductsThe following CPT and HCPCS codes are in-scope under the AIM Advanced Imaging/RadiologyManagement Program for Medicare HMO and PPO. For medical necessity criteria, see AIM ClinicalAppropriateness Guidelines for Advanced Imaging/Radiology.CPT Codes / HCPCS Codes / ICD CodesInclusion or exclusion of a code does not constitute or imply member coverage or providerreimbursement. Please refer to the member’s contract benefits in effect at the time of service to determinecoverage or non-coverage as it applies to an individual member.Providers should report all services using the most up-to-date industry-standard procedure, revenue, anddiagnosis codes, including modifiers where applicable.The following codes are included below for informational purposes only; this is not an all-inclusive list.The above medical necessity criteria MUST be met for the following codes to be covered forCommercial Members: Managed Care (HMO and POS), PPO, and Indemnity:CPT Codes: 70336 MRI of Temporomandibular Joint(s)CPTcodes:70336Code DescriptionMRI of Temporomandibular Joint(s)The following ICD Diagnosis Codes are considered medically necessary when submitted with theCPT codes above if medical necessity criteria are met:ICD-10 Diagnosis CodingICD-10CodeA17.0ICD-10 NameA17.1A17.81A17.82A17.83A17.89A18.03Meningeal tuberculomaTuberculoma of brain and spinal cordTuberculous meningoencephalitisTuberculous neuritisOther tuberculosis of nervous systemTuberculosis of other s peripheral lymphadenopathyTuberculosis of eye, unspecifiedTuberculous episcleritisTuberculous keratitisTuberculous chorioretinitisTuberculous iridocyclitisA18.59A18.6A18.81A41.9Other tuberculosis of eyeTuberculosis of (inner) (middle) earTuberculosis of thyroid glandSepsis, unspecified organismTuberculous meningitis2
A42.2A42.81A42.82A49.01Cervicofacial actinomycosisActinomycotic meningitisActinomycotic encephalitisMethicillin susceptible Staphylococcus aureus infection, unspecified siteA49.02A49.1A49.2A49.3A49.8A49.9Methicillin resistant Staphylococcus aureus infection, unspecified siteStreptococcal infection, unspecified siteHemophilus influenzae infection, unspecified siteMycoplasma infection, unspecified siteOther bacterial infections of unspecified siteBacterial infection, e congenital neurosyphilis, unspecifiedLate congenital syphilitic meningitisLate congenital syphilitic encephalitisLate congenital syphilitic polyneuropathyJuvenile general paresisOther late congenital econdary syphilitic oculopathySymptomatic neurosyphilis, unspecifiedTabes dorsalisOther cerebrospinal syphilisLate syphilitic meningitisLate syphilitic encephalitisA52.15A52.16A52.17A52.19A52.2A52.3Late syphilitic neuropathyCharcot's arthropathy (tabetic)General paresisOther symptomatic neurosyphilisAsymptomatic neurosyphilisNeurosyphilis, coccal infection of eye, unspecifiedGonococcal conjunctivitisGonococcal iridocyclitisGonococcal keratitisOther gonococcal eye infectionChlamydial ther chlamydial diseasesCreutzfeldt-Jakob Disease, UnspecifiedVariant Creutzfeldt-Jakob DiseaseOther Creutzfeldt-Jakob DiseaseProgressive multifocal leukoencephalopathyOther atypical virus infections of central nervous systemA81.9A82.0A82.1Atypical virus infection of central nervous system, unspecifiedSylvatic rabiesUrban rabies3
A82.9A83.0A83.1A83.2Rabies, unspecifiedJapanese encephalitisWestern equine encephalitisEastern equine encephalitisA83.3A83.4A83.5A83.6A83.8A83.9St Louis encephalitisAustralian encephalitisCalifornia encephalitisRocio virus diseaseOther mosquito-borne viral encephalitisMosquito-borne viral encephalitis, unspecifiedA85.0A85.1A85.2A85.8A86A87.0Enteroviral encephalitisAdenoviral encephalitisArthropod-borne viral encephalitis, unspecifiedOther specified viral encephalitisUnspecified viral encephalitisEnteroviral meningitisA87.1A87.2A87.8A87.9A88.8A89Adenoviral meningitisLymphocytic choriomeningitisOther viral meningitisViral meningitis, unspecifiedOther specified viral infections of central nervous systemUnspecified viral infection of central nervous al meningitisHerpesviral iridocyclitisHerpesviral keratitisHerpesviral conjunctivitisOther herpesviral disease of eyeVaricella encephalitis and .34Other postherpetic nervous system involvementZoster ocular disease, unspecifiedZoster conjunctivitisZoster iridocyclitisZoster keratitisZoster scleritisB02.39B05.0B06.01B06.81B06.89B20Other herpes zoster eye diseaseMeasles complicated by encephalitisRubella encephalitisRubella pneumoniaOther rubella complicationsHuman immunodeficiency virus [HIV] diseaseB25.0B25.1B25.2Cytomegaloviral pneumonitisCytomegaloviral hepatitisCytomegaloviral pancreatitis4
B25.8B25.9B26.2B30.0Other cytomegaloviral diseasesCytomegaloviral disease, unspecifiedMumps encephalitisKeratoconjunctivitis due to itis due to adenovirusViral pharyngoconjunctivitisAcute epidemic hemorrhagic conjunctivitis (enteroviral)Other viral conjunctivitisCandidal meningitisCoccidioidomycosis meningitisB44.0B44.1B44.2B44.7B44.89B44.9Invasive pulmonary aspergillosisOther pulmonary aspergillosisTonsillar aspergillosisDisseminated aspergillosisOther forms of aspergillosisAspergillosis, unspecifiedB45.0B45.1B45.2B45.3B45.7B45.8Pulmonary cryptococcosisCerebral cryptococcosisCutaneous cryptococcosisOsseous cryptococcosisDisseminated cryptococcosisOther forms of ccosis, unspecifiedPenicillosisOther specified mycosesToxoplasma meningoencephalitisUnspecified protozoal diseaseCysticercosis of central nervous systemB69.1B69.81B69.89B69.9B75B89Cysticercosis of eyeMyositis in cysticercosisCysticercosis of other sitesCysticercosis, unspecifiedTrichinellosisUnspecified parasitic diseaseB90.0B94.1B95.0B95.1B95.2B95.3Sequelae of central nervous system tuberculosisSequelae of viral encephalitisStreptococcus, group A, as the cause of diseases classified elsewhereStreptococcus, group B, as the cause of diseases classified elsewhereEnterococcus as the cause of diseases classified elsewhereStreptococcus pneumoniae as the cause of diseases classified elsewhereB95.4B95.5Other streptococcus as the cause of diseases classified elsewhereUnspecified streptococcus as the cause of diseases classified elsewhere5
B97.10B97.33Methicillin susceptible Staphylococcus aureus infection as the cause of diseasesclassified elsewhereMethicillin resistant Staphylococcus aureus infection as the cause of diseases classifiedelsewhereOther staphylococcus as the cause of diseases classified elsewhereMycoplasma pneumoniae [M. pneumoniae] as the cause of diseases classified elsewhereKlebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhereUnspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhereShiga toxin-producing Escherichia coli [E. coli] (STEC) O157 as the cause of diseasesclassified elsewhereOther specified Shiga toxin-producing Escherichia coli [E. coli] (STEC) as the cause ofdiseases classified elsewhereUnspecified Shiga toxin-producing Escherichia coli [E. coli] (STEC) as the cause ofdiseases classified elsewhereOther Escherichia coli [E. coli] as the cause of diseases classified elsewhereHemophilus influenzae [H. influenzae] as the cause of diseases classified elsewhereProteus (mirabilis) (morganii) as the cause of diseases classified elsewherePseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classifiedelsewhereBacteroides fragilis [B. fragilis] as the cause of diseases classified elsewhereClostridium perfringens [C. perfringens] as the cause of diseases classified elsewhereHelicobacter pylori [H. pylori] as the cause of diseases classified elsewhereB97.89B99.9G50.1K13.79Vibrio vulnificus as the cause of diseases classified elsewhereOther specified bacterial agents as the cause of diseases classified elsewhereUnspecified enterovirus as the cause of diseases classified elsewhereHuman T-cell lymphotrophic virus, type I [HTLV-I] as the cause of diseases classifiedelsewhereOther viral agents as the cause of diseases classified elsewhereUnspecified infectious diseaseAtypical facial painOther lesions of oral tic juvenile arthropathyPyogenic arthritis, unspecifiedUnspecified juvenile rheumatoid arthritis of unspecified siteUnspecified Juvenile Rheumatoid Arthritis, Right ShoulderUnspecified Juvenile Rheumatoid Arthritis, Left ShoulderUnspecified Juvenile Rheumatoid Arthritis, Unspecified Unspecified Juvenile Rheumatoid Arthritis, Right ElbowUnspecified Juvenile Rheumatoid Arthritis, Left ElbowUnspecified Juvenile Rheumatoid Arthritis, Unspecified ElbowUnspecified Juvenile Rheumatoid Arthritis, Right WristUnspecified Juvenile Rheumatoid Arthritis, Left WristUnspecified Juvenile Rheumatoid Arthritis, Unspecified WristM08.041M08.042M08.049Unspecified Juvenile Rheumatoid Arthritis, Right HandUnspecified Juvenile Rheumatoid Arthritis, Left HandUnspecified Juvenile Rheumatoid Arthritis, Unspecified Hand6
M08.051M08.052M08.059M08.061Unspecified Juvenile Rheumatoid Arthritis, Right HipUnspecified Juvenile Rheumatoid Arthritis, Left HipUnspecified Juvenile Rheumatoid Arthritis, Unspecified HipUnspecified Juvenile Rheumatoid Arthritis, Right cified Juvenile Rheumatoid Arthritis, Left KneeUnspecified Juvenile Rheumatoid Arthritis, Unspecified KneeUnspecified Juvenile Rheumatoid Arthritis, Right Ankle And FootUnspecified Juvenile Rheumatoid Arthritis, Left Ankle And FootUnspecified Juvenile Rheumatoid Arthritis, Unspecified Ankle And FootUnspecified Juvenile Rheumatoid Arthritis, pecified juvenile rheumatoid arthritis, multiple sitesJuvenile Ankylosing SpondylitisJuvenile Rheumatoid Arthritis With Systemic Onset, Unspecified SiteJuvenile Rheumatoid Arthritis With Systemic Onset, Right ShoulderJuvenile Rheumatoid Arthritis With Systemic Onset, Left ShoulderJuvenile Rheumatoid Arthritis With Systemic Onset, Unspecified Juvenile Rheumatoid Arthritis With Systemic Onset, Right ElbowJuvenile Rheumatoid Arthritis With Systemic Onset, Left ElbowJuvenile Rheumatoid Arthritis With Systemic Onset, Unspecified ElbowJuvenile Rheumatoid Arthritis With Systemic Onset, Right WristJuvenile Rheumatoid Arthritis With Systemic Onset, Left WristJuvenile Rheumatoid Arthritis With Systemic Onset, Unspecified enile Rheumatoid Arthritis With Systemic Onset, Right HandJuvenile Rheumatoid Arthritis With Systemic Onset, Left HandJuvenile Rheumatoid Arthritis With Systemic Onset, Unspecified HandJuvenile Rheumatoid Arthritis With Systemic Onset, Right HipJuvenile Rheumatoid Arthritis With Systemic Onset, Left HipJuvenile Rheumatoid Arthritis With Systemic Onset, Unspecified ile Rheumatoid Arthritis With Systemic Onset, Right KneeJuvenile Rheumatoid Arthritis With Systemic Onset, Left KneeJuvenile Rheumatoid Arthritis With Systemic Onset, Unspecified KneeJuvenile Rheumatoid Arthritis With Systemic Onset, Right Ankle And FootJuvenile Rheumatoid Arthritis With Systemic Onset, Left Ankle And FootJuvenile Rheumatoid Arthritis With Systemic Onset, Unspecified Ankle And FootM08.28M08.29M08.3M08.40M08.411M08.412Juvenile Rheumatoid Arthritis With Systemic Onset, VertebraeJuvenile Rheumatoid Arthritis With Systemic Onset, Multiple SitesJuvenile Rheumatoid Polyarthritis (Seronegative)Pauciarticular Juvenile Rheumatoid Arthritis, Unspecified SitePauciarticular Juvenile Rheumatoid Arthritis, Right ShoulderPauciarticular Juvenile Rheumatoid Arthritis, Left ShoulderM08.419M08.421M08.422Pauciarticular Juvenile Rheumatoid Arthritis, Unspecified ShoulderPauciarticular Juvenile Rheumatoid Arthritis, Right ElbowPauciarticular Juvenile Rheumatoid Arthritis, Left Elbow7
M08.429M08.431M08.432M08.439Pauciarticular Juvenile Rheumatoid Arthritis, Unspecified ElbowPauciarticular Juvenile Rheumatoid Arthritis, Right WristPauciarticular Juvenile Rheumatoid Arthritis, Left WristPauciarticular Juvenile Rheumatoid Arthritis, Unspecified ciarticular Juvenile Rheumatoid Arthritis, Right HandPauciarticular Juvenile Rheumatoid Arthritis, Left HandPauciarticular Juvenile Rheumatoid Arthritis, Unspecified HandPauciarticular Juvenile Rheumatoid Arthritis, Right HipPauciarticular Juvenile Rheumatoid Arthritis, Left HipPauciarticular Juvenile Rheumatoid Arthritis, Unspecified articular Juvenile Rheumatoid Arthritis, Right KneePauciarticular Juvenile Rheumatoid Arthritis, Left KneePauciarticular Juvenile Rheumatoid Arthritis, Unspecified KneePauciarticular Juvenile Rheumatoid Arthritis, Right Ankle And FootPauciarticular Juvenile Rheumatoid Arthritis, Left Ankle And FootPauciarticular Juvenile Rheumatoid Arthritis, Unspecified Ankle And rticular Juvenile Rheumatoid Arthritis, VertebraeOther Juvenile Arthritis, Unspecified SiteOther Juvenile Arthritis, Right ShoulderOther Juvenile Arthritis, Left ShoulderOther Juvenile Arthritis, Unspecified ShoulderOther Juvenile Arthritis, Right er Juvenile Arthritis, Left ElbowOther Juvenile Arthritis, Unspecified ElbowOther Juvenile Arthritis, Right WristOther Juvenile Arthritis, Left WristOther Juvenile Arthritis, Unspecified WristOther Juvenile Arthritis, Right r Juvenile Arthritis, Left HandOther Juvenile Arthritis, Unspecified HandOther Juvenile Arthritis, Right HipOther Juvenile Arthritis, Left HipOther Juvenile Arthritis, Unspecified HipOther Juvenile Arthritis, Right KneeM08.862M08.869M08.871M08.872M08.879M08.88Other Juvenile Arthritis, Left KneeOther Juvenile Arthritis, Unspecified KneeOther Juvenile Arthritis, Right Ankle And FootOther Juvenile Arthritis, Left Ankle And FootOther Juvenile Arthritis, Unspecified Ankle And FootOther juvenile arthritis, other specified siteM08.89M08.90M08.911Other Juvenile Arthritis, Multiple SitesJuvenile arthritis, unspecified, unspecified siteJuvenile Arthritis, Unspecified, Right Shoulder8
M08.912M08.919M08.921M08.922Juvenile Arthritis, Unspecified, Left ShoulderJuvenile Arthritis, Unspecified, Unspecified ShoulderJuvenile Arthritis, Unspecified, Right ElbowJuvenile Arthritis, Unspecified, Left enile Arthritis, Unspecified, Unspecified ElbowJuvenile Arthritis, Unspecified, Right WristJuvenile Arthritis, Unspecified, Left WristJuvenile Arthritis, Unspecified, Unspecified WristJuvenile Arthritis, Unspecified, Right HandJuvenile Arthritis, Unspecified, Left nile Arthritis, Unspecified, Unspecified HandJuvenile Arthritis, Unspecified, Right HipJuvenile Arthritis, Unspecified, Left HipJuvenile Arthritis, Unspecified, Unspecified HipJuvenile Arthritis, Unspecified, Right KneeJuvenile Arthritis, Unspecified, Left le Arthritis, Unspecified, Unspecified KneeJuvenile Arthritis, Unspecified, Right Ankle And FootJuvenile Arthritis, Unspecified, Left Ankle And FootJuvenile Arthritis, Unspecified, Unspecified Ankle And FootJuvenile Arthritis, Unspecified, VertebraeJuvenile Arthritis, Unspecified, Multiple SitesM12.58M12.88M12.9M19.09M19.19M19.90Traumatic arthropathy, other specified siteOther specific arthropathies, not elsewhere classified, other specified siteArthropathy, unspecifiedPrimary osteoarthritis, other specified sitePost-traumatic osteoarthritis, other specified siteUnspecified osteoarthritis, unspecified siteM19.91M19.92M26.00M26.01M26.02M26.03Primary osteoarthritis, unspecified sitePost-traumatic osteoarthritis, unspecified siteUnspecified anomaly of jaw sizeMaxillary hyperplasiaMaxillary hypoplasiaMandibular dibular hypoplasiaMacrogeniaMicrogeniaExcessive tuberosity of jawOther specified anomalies of jaw sizeUnspecified anomaly of jaw-cranial base relationshipM26.11M26.12M26.19Maxillary asymmetryOther jaw asymmetryOther specified anomalies of jaw-cranial base relationship9
M26.29M26.51M26.52M26.53Other anomalies of dental arch relationshipAbnormal jaw closureLimited mandibular range of motionDeviation in opening and closing of the icient anterior guidanceCentric occlusion maximum intercuspation discrepancyNon-working side interferenceLack of posterior occlusal supportOther dentofacial functional abnormalitiesTemporomandibular joint disorder, 11Right temporomandibular joint disorder,Left temporomandibular joint disorder,Bilateral temporomandibular joint disorder,Unspecified temporomandibular joint disorderAdhesions and ankylosis of temporomandibular jointAdhesions and ankylosis of right temporomandibular sions and ankylosis of left temporomandibular jointAdhesions and ankylosis of bilateral temporomandibular jointAdhesions and ankylosis of temporomandibular joint, unspecified sideArthralgia of temporomandibular jointArthralgia of right temporomandibular jointArthralgia of left temporomandibular ralgia of bilateral temporomandibular jointArthralgia of temporomandibular joint,Articular disc disorder of temporomandibular jointArticular disc disorder of right temporomandibular jointArticular disc disorder of left temporomandibular jointArticular disc disorder of bilateral temporomandibular icular disc disorder of temporomandibular joint, unspecified sideArthritis of right temporomandibular jointArthritis of left temporomandibular jointArthritis of bilateral temporomandibular jointArthritis of unspecified temporomandibular jointArthropathy of right temporomandibular thy of left temporomandibular jointArthropathy of bilateral temporomandibular jointArthropathy of unspecified temporomandibular jointOther specified disorders of temporomandibular jointOther specified diseases of jawsDisease of jaws, unspecifiedM86.10M86.18M86.20Other acute osteomyelitis, unspecified siteOther acute osteomyelitis, other siteSubacute osteomyelitis, unspecified site10
M86.28M86.30M86.38M86.40Subacute osteomyelitis, other siteChronic multifocal osteomyelitis, unspecified siteChronic multifocal osteomyelitis, other siteChronic osteomyelitis with draining sinus, unspecified siteM86.48M86.50M86.58M86.60M86.68M86.8X8Chronic osteomyelitis with draining sinus, other siteOther chronic hematogenous osteomyelitis, unspecified siteOther chronic hematogenous osteomyelitis, other siteOther chronic osteomyelitis, unspecified siteOther chronic osteomyelitis, other siteOther osteomyelitis, other siteM86.8X9M86.9R25.2R29.91R51.0R51.9Other osteomyelitis, unspecified sitesOsteomyelitis, unspecifiedCramp and spasmUnspecified symptoms and signs involving the musculoskeletal systemHeadache with orthostatic component, not elsewhere classifiedHeadache, 401SJaw painAbnormal findings on diagnostic imaging of skull and head, not elsewhere classifiedMaxillary fracture, unspecified, initial encounter for closed fractureMaxillary fracture, unspecified, subsequent encounter for fracture with delayed healingMaxillary fracture, unspecified side, subsequent encounter for fracture with nonunionMaxillary fracture, unspecified, .40CGMaxillary fracture, unspecified, initial encounter for open fractureMaxillary fracture, unspecified, subsequent encounter for fracture with routine healingMaxillary fracture, right side, initial encounter for closed fractureMaxillary fracture, right side, initial encounter for open fractureMaxillary fracture, right side, subsequent encounter for fracture with routine healingMaxillary fracture, right side, subsequent encounter for fracture with delayed .40DGMaxillary fracture, right side, subsequent encounter for fracture with nonunionMaxillary fracture, right side, sequelaMaxillary fracture, left side, initial encounter for closed fractureMaxillary fracture, left side, initial encounter for open fractureMaxillary fracture, left side, subsequent encounter for fracture with routine healingMaxillary fracture, left side, subsequent encounter for fracture with delayed .01XAMaxillary fracture, left side, subsequent encounter for fracture with nonunionMaxillary fracture, left side, sequelaDislocation of jaw, unspecified side, initial encounterDislocation of jaw, unspecified side, subsequent encounterDislocation of jaw, unspecified side, sequelaDislocation of jaw, right side, initial encounterS03.01XDS03.01XSS03.02XADislocation of jaw, right side, subsequent encounterDislocation of jaw, right side, sequelaDislocation of jaw, left side, initial encounter11
S03.02XDS03.02XSS03.03XAS03.03XDDislocation of jaw, left side, subsequent encounterDislocation of jaw, left side, sequelaDislocation of jaw, bilateral, initial encounterDislocation of jaw, bilateral, subsequent 03.40XDDislocation of jaw, bilateral, sequelaDislocation of jaw, initial encounterDislocation of jaw, subsequent encounterDislocation of jaw, sequelaSprain of jaw, unspecified side, initial encounterSprain of jaw, unspecified side, subsequent 03.42XDSprain of jaw, unspecified side, sequelaSprain of jaw, right side, initial encounterSprain of jaw, right side, subsequent encounterSprain of jaw, right side, sequelaSprain of jaw, left side, initial encounterSprain of jaw, left side, subsequent 03.4XXDSprain of jaw, left side, sequelaSprain of jaw, bilateral, initial encounterSprain of jaw, bilateral, subsequent encounterSprain of jaw, bilateral, sequelaSprain of jaw, initial encounterSprain of jaw, subsequent encounterS03.4XXSSprain of jaw, sequelaThe above medical necessity criteria MUST be met for the following codes to be covered forCommercial Members: Managed Care (HMO and POS), PPO, and Indemnity:CPT Codes: 70486, 70487, 70488 CT of maxillofacial areaCPTcodes:704867048770488Code DescriptionCT of maxillofacial area, without contrastCT of maxillofacial area, with contrastCT of maxillofacial area, without contrast, followed by re-imaging with contrastThe following ICD Diagnosis Codes are considered medically necessary when submitted with theCPT codes above if medical necessity criteria are met:ICD-10 Diagnosis escriptionG96.08Other cranial cerebrospinal fluid leakMycetoma, unspecifiedAtypical facial painCerebrospinal fluid leak, unspecifiedCranial cerebrospinal fluid leak, spontaneousSpinal cerebrospinal fluid leak, spontaneous12
G96.09H05.221H05.222H05.223Other spinal cerebrospinal fluid leakEdema of right orbitEdema of left orbitEdema of bilateral orbitH05.229J01.00J01.01J01.10J01.11J01.20Edema of unspecified orbitAcute maxillary sinusitis, unspecifiedAcute recurrent maxillary sinusitisAcute frontal sinusitis, unspecifiedAcute recurrent frontal sinusitisAcute ethmoidal sinusitis, te recurrent ethmoidal sinusitisAcute sphenoidal sinusitis, unspecifiedAcute recurrent sphenoidal sinusitisAcute pansinusitis, unspecifiedAcute recurrent pansinusitisOther acute sinusitisJ01.81J01.90J01.91J30.1J30.2J30.89Other acute recurrent sinusitisAcute sinusitis, unspecifiedAcute recurrent sinusitis, unspecifiedAllergic rhinitis due to pollenOther seasonal allergic rhinitisOther allergic rhinitisJ30.9J31.0J31.1J31.2J32.0J32.1Allergic rhinitis, unspecifiedChronic rhinitisChronic nasopharyngitisChronic pharyngitisChronic maxillary sinusitisChronic frontal sinusitisJ32.2J32.3J32.4J32.8J32.9J33.0Chronic ethmoidal sinusitisChronic sphenoidal sinusitisChronic pansinusitisOther chronic sinusitisChronic sinusitis, unspecifiedPolyp of nasal cavityJ33.1J33.8J33.9J34.0J34.1J34.2Polypoid sinus degenerationOther polyp of sinusNasal polyp, unspecifiedAbscess, furuncle and carbuncle of noseCyst and mucocele of nose and nasal sinusDeviated nasal septumJ34.3J34.81J34.89Hypertrophy of nasal turbinatesNasal mucositis (ulcerative)Other specified disorders of nose and nasal sinuses13
J34.9J35.2J39.2J39.8Unspecified disorder of nose and nasal sinusesHypertrophy of adenoidsOther diseases of pharynxOther specified diseases of upper respiratory tractK00.1K00.6K01.0K01.1K02.9K04.01Supernumerary teethDisturbances in tooth eruptionEmbedded teethImpacted teethDental caries, unspecifiedReversible e pulpitisNecrosis of pulpPulp degenerationAbnormal hard tissue formation in pulpAcute apical periodontitis of pulpal originChronic apical ical abscess with sinusPeriapical abscess without sinusRadicular cystDisorder of teeth and supporting structures, unspecifiedCellulitis and abscess of mouthOther lesions of oral 6.09Cutaneous abscess of faceCellulitis of faceArthropathic psoriasis, unspecifiedRheumatoid arthritis of multiple sites with involvement of other organs and systemsRheumatoid arthritis with rheumatoid factor of multiple sites without organ or systemsinvolvementOther rheumatoid arthritis with rheumatoid factor of multiple sitesRheumatoid arthritis with rheumatoid factor, unspecifiedRheumatoid arthritis without rheumatoid factor, multiple sitesM06.89M06.9M08.3M19.09M19.19M19.90Other specified rheumatoid arthritis, multiple sitesRheumatoid arthritis, unspecifiedJuvenile rheumatoid polyarthritis (seronegative)Primary osteoarthritis, other specified sitePost-traumatic osteoarthritis, other specified siteUnspecified osteoarthritis, unspecified siteM19.91M19.92M19.93M26.00M26.01M26.02Primary osteoarthritis, unspecified sitePost-traumatic osteoarthritis, unspecified siteSecondary osteoarthritis, unspecified siteUnspecified anomaly of jaw sizeMaxillary hyperplasiaMaxillary hypoplasia14
M26.03M26.04M26.05M26.06Mandibular hyperplasiaMandibular 6.11M26.12M26.19Excessive tuberosity of jawOther specified anomalies of jaw sizeUnspecified anomaly of jaw-cranial base relationshipMaxillary asymmetryOther jaw asymmetryOther specified anomalies of jaw-cranial base her anomali
Head and Neck Imaging CPT, HCPCS and Diagnoses Codes Policy Number: 934 BCBSA Reference Number: N/A NCD/LCD: N/A Related Policies Medicare Advantage: Advanced Imaging/Radiology and Sleep Disorder Management Clinical and Utilization Guidance Redirect, #923 Advanced
