D7877 Arthroscopy Surgical; Debridement NO NO Not Covered – D7880 Occlusal Orthotic Device Yes Yes Yes Yes $250.00 Unspecified TMD Therapy, by Report NO NO Not Covered REPAIR OF TRAUMATIC WOUNDS D7910 Suture of Recent Wounds Up to 5 cm YES Yes No No $84.75 COMPLICATED SUTURING (RECONSTRUCTION REQUIRING DELICATE HANDLING OF TISSUES AND WIDE UNDERMINING FOR METICULOUS CLOSURE) D7911 Complicated Suture - Up to 5 cm Yes Yes No No $193.00 D7912 Complicated Suture Greater Than 5 cm Yes Yes No No $263.50 – Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code under age age 21 & under age age 21 & 21 & all over when 21 & all over when ICF-IID allowed ICF-IID allowed residents* under residents under 25.04 25.04 OTHER REPAIR PROCEDURES D7920 Skin Grafts (identify defect covered, location, and type NO NO Not Covered of graft) D7921 Collection and Application of Autologous Blood NO NO Not Covered Concentrate Product D7940 Osteoplasty for Orthognathic Deformities YES YES YES YES By Report D7941 Osteotomy Mandibular Rami YES YES YES YES By Report –
D7877 Arthroscopy – Surgical; Debridement NO NO Not Covered D7880 Occlusal Orthotic Device Yes Yes Yes Yes $250.00 Unspecified TMD Therapy, by Report NO NO Not Covered REPAIR OF TRAUMATIC WOUNDS D7910 Suture of Recent Wounds Up to 5 cm YES Yes No No $84.75 COMPLICATED SUTURING (RECONSTRUCTION REQUIRING DELICATE HANDLING OF TISSUES AND WIDE UNDERMINING FOR METICULOUS CLOSURE) D7911 Complicated Suture - Up to 5 cm Yes Yes No No $193.00 D7912 Complicated Suture – Greater Than 5 cm Yes Yes No No $263.50 Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under age 21 & all ICF-IID residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 OTHER REPAIR PROCEDURES D7920 Skin Grafts (identify defect covered, location, and type of graft) NO NO Not Covered D7921 Collection and Application of Autologous Blood Concentrate Product NO NO Not Covered D7940 Osteoplasty for Orthognathic Deformities YES YES YES YES By Report D7941 Osteotomy – Mandibular Rami YES YES YES YES By Report
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