Does D21.20 require prior authorization?

No, D21.20 does not require prior authorization (high confidence). Covered without prior authorization.

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`D21.20`, Benign neoplasm of connective and other soft tissue of unspecified lower limb, including hip

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

When billing J7999-KD, enter the name and total dose (mg or mcg) of each drug in Box 19 of the CMS-1500 or the appropriate electronic comment loop; if Box 19 cannot accommodate all information, attach the details to the paper claim.
If a portion of a single-dose vial is not used, submit the HCPCS code for the drug on a separate claim line and append modifier JW to indicate discarded/unused portion.
Separate payment may be made for pump refilling and/or adjustments; submit these services using the appropriate drug refill or maintenance CPT/HCPCS code that accurately describes the service rendered.

Compounded drugs are priced by the A/B MAC contractor by multiplying the contractor's price per mcg or mg by the total number of mcg or mg of each drug used; a pharmacy compounding fee may be allowed in addition to the calculated drug amount.

Use the listed CPT/HCPCS codes when billing for opioid drugs or procedures related to implantable pumps for chronic intractable pain: J7999-KD, E0782, E0783, E0785, E0786, J2274 (example), J2278-KD, 62327, 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 62369, 62370, 95990, 95991.

Key Coverage Criteria

Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.
True off-the-shelf (non‑compounded) drugs used without compounding and administered via DME may be billed using the drug-specific HCPCS code and are reimbursed under CMS ASP methodology.
If Prialt® is implanted as a single agent in the pump, bill using HCPCS code J2278-KD.
Compounded single-agent or combination drug formulations used in implanted infusion pumps must be billed using HCPCS code J7999-KD for reimbursement.
Simultaneous bilateral hip or knee replacement during the same encounter is covered when medical necessity for bilateral procedure is documented; bilateral procedures are subject to bilateral pricing.
Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is covered for advanced joint disease when arthritis of the hip or knee is supported by X-ray or MRI demonstrating subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis.

6 Active Policies

FIRST_COAST-L33618, Major Joint Replacement (Hip and Knee)

FIRST_COAST-L33933, Peripheral Nerve Blocks

A57765, Billing and Coding: Major Joint Replacement (Hip and Knee)

AETNA-CPB-0171, Magnetic Resonance Imaging (MRI) of the Extremities

A56695, Billing and Coding: Implantable Infusion Pump

A57788, Billing and Coding: Peripheral Nerve Blocks

`D21.20`, Benign neoplasm of connective and other soft tissue of unspecified lower limb, including hip

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

D21.20, Benign neoplasm of connective and other soft tissue of unspecified lower limb, including hip

Prior Authorization

Documentation Required

Key Coverage Criteria

6 Active Policies

Related Codes

Have a follow-up question?

`D21.20`, Benign neoplasm of connective and other soft tissue of unspecified lower limb, including hip