Does M12.861 require prior authorization?

No, M12.861 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`M12.861`, Other specific arthropathies, not elsewhere classified, right knee

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

Patient record must document BMI >= 35, at least one obesity-related comorbidity, and a primary diagnosis of morbid obesity (ICD-10-CM E66.01) for bariatric surgery claims.
Documentation of prior conservative medical treatment: active participation within the 12 months prior to surgery in a physician- or healthcare professional-supervised weight-management program for a minimum of four consecutive months with monthly documentation of weight and BMI, current dietary regimen, and physical activity.
A thorough multidisciplinary evaluation within the previous 6 months must include: (a) surgeon evaluation recommending the procedure and describing the proposed procedure, (b) separate non-surgeon physician medical evaluation with recommendation and medical clearance, (c) mental health/psychosocial clearance including a statement on motivation and ability to follow post-surgical requirements, and (d) nutritional evaluation by a physician or registered dietician.

Key Coverage Criteria

Roux-en-Y gastric bypass (RYGBP) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Laparoscopic adjustable gastric banding (AGB) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Laparoscopic sleeve gastrectomy is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Occupational therapy is covered for patients with migraine (G43.xx) who require training to reduce pain during basic and instrumental activities of daily living, typically completed in 3–4 sessions.
Electrical stimulation (attended CPT 97032 or unattended HCPCS G0283) may be covered as part of a therapy plan of care to improve function when the nerve supply to the muscle is intact and atrophy is due to non-neurological disuse (e.g., post-casting, splinting, soft-tissue scarring).

13 Active Policies

A59434, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59764, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A53065, Billing and Coding: Outpatient Physical Therapy

A56852, Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity

ANTHEM-SURG.00142, Genicular Procedures for Treatment of Knee Pain

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A57685, Billing and Coding: Total Knee Arthroplasty

A53026, Billing and Coding: Bariatric Surgery Coverage

A53057, Billing and Coding: Home Health Occupational Therapy

A53064, Billing and Coding: Outpatient Occupational Therapy

`M12.861`, Other specific arthropathies, not elsewhere classified, right knee

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

M12.861, Other specific arthropathies, not elsewhere classified, right knee

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

`M12.861`, Other specific arthropathies, not elsewhere classified, right knee