CPT 21040, in plain terms, covers Removal of a benign tumor or cyst of the lower jaw by enucleation or curettage. CPT 21040 is referenced in 8 tracked payer policy changes from UnitedHealthcare, Regence BlueShield, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 21040 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 21040 on AAPC
UnitedHealthcare is removing a long list of CPT codes from the applicable-code list of its Outpatient Surgical Procedures site-of-service policy for Exchange plans, and it is also removing the link to the Manipulation Under Anesthesia policy. The change takes effect December 1, 2026. The source does not state a new billing requirement for the removed codes.
Effective December 1, 2026, UMR removes more than 500 CPT codes from its Outpatient Surgical Procedures - Site of Service medical policy for commercial plans, and it drops a reference link to the Manipulation Under Anesthesia policy. For those codes, UMR's site-of-service policy no longer applies, so the practice should update its internal UMR site-of-service and prior authorization lists before that date.
Effective December 1, 2026, UnitedHealthcare removes more than 500 CPT codes from its Outpatient Surgical Procedures - Site of Service medical policy for commercial plans, and it drops a reference link to the Manipulation Under Anesthesia policy. For those codes, the site-of-service policy no longer applies under this UnitedHealthcare commercial policy, so the practice should update its internal site-of-service and prior authorization lists before that date.
Effective November 1, 2026, site of care medical necessity reviews apply to the listed surgical procedures only when they are performed in an outpatient hospital setting. Use of a hospital outpatient department instead of an ambulatory surgery center or physician office may be considered medically necessary when one or more listed criteria are met, such as no geographically accessible in-network ASC that has the necessary equipment, a procedure that requires discontinuing medications that necessitate inpatient monitoring or treatment, ASA Physical Status III or higher, or a BMI over 40. Hospital outpatient use is considered not medically necessary when the criteria are not met.
This surgical site of care policy sets criteria for when a hospital outpatient department may be considered medically necessary instead of an ambulatory surgery center or physician office for listed surgical procedures. Hospital outpatient use may be considered medically necessary when one or more criteria are met, such as no qualifying in-network ASC within 25 miles that can provide the necessary care, an ASA Physical Status Classification of III or higher, a body mass index over 40, or a surgery expected to last longer than 3 hours. Use of a hospital outpatient department instead of an ASC or physician office is considered not medically necessary when the criteria are not met. The procedure may require prior authorization separately under its own medical policy.
Surgery for neuralgia inducing cavitational osteonecrosis (NICO) is considered experimental, investigational or unproven, including scraping of infected cavities and removal of root-canal-treated teeth. Rinsing the cavity with colloidal silver, chelation therapy with intravenous vitamin C, and bone graft replacement for NICO-related diagnoses are also considered experimental, investigational or unproven. Devices that image the jawbones to diagnose NICO or NICO-type conditions are considered experimental, investigational or unproven because there is no adequate scientific evidence to support their clinical value.
Aetna's Clinical Policy Bulletin 0642 considers surgery for neuralgia inducing cavitational osteonecrosis (NICO) related diagnoses experimental, investigational or unproven, including scraping of infected cavities and removal of root-canal-treated teeth. Other NICO therapies are also listed as experimental, investigational or unproven, namely rinsing the cavity with colloidal silver, chelation therapy, intravenous vitamin C and bone graft replacement. Devices that image the jawbones to diagnose NICO or NICO-type conditions are experimental, investigational or unproven because there is no adequate scientific evidence to support their clinical value, and the policy states that current evidence is insufficient to support NICO as a distinct, validated clinical entity.
Aetna medical plans generally exclude routine dental care. Indemnity, PPO and Managed Choice plans generally cover certain oral and maxillofacial surgery services related to the jaw or facial bones, such as surgery to alter the jaw or bite when non-surgical management cannot produce functional improvement, removal of cysts and tumors, and surgical removal of teeth that will not erupt or are impacted in the bone. Pediatric orthodontics is covered only under a pediatric oral health benefit for a severe handicapping malocclusion related to a qualifying medical condition. Bone grafts into extraction sites are considered not medically necessary, except for impacted third molar extraction sites when bony defects are clinically significant and the patient is 26 years of age or older.
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