Does M16.10 require prior authorization?

No, M16.10 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`M16.10`, Unilateral primary osteoarthritis, unspecified hip

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

Claims for covered bariatric surgery must include three diagnosis codes with the primary diagnosis as E66.01, E66.812, or E66.813 and secondary/tertiary diagnoses from the specified ICD-10-CM code groups (group 1 and group 2).
When using CPT 43843 or CPT 43999 to bill a Not Otherwise Classified (NOC) or specific open procedures, include a note identifying the specific test/procedure performed in the Remarks area for Part A claims and the Narrative area for Part B claims.
Refer to LCD L35022 for complete reasonable-and-necessary documentation requirements and retain supporting medical records as required by Medicare policy.

Key Coverage Criteria

Coverage for selected bariatric surgical procedures is allowed only for patients who meet the national and local reasonable-and-necessary criteria set forth in LCD L35022.
Claims for covered bariatric procedures must report three diagnoses: a primary diagnosis of morbid obesity (one of E66.01, E66.812, or E66.813), a secondary diagnosis from ICD-10-CM Code group 1, and a tertiary diagnosis from ICD-10-CM Code group 2.
Use CPT 43659 when both the gastric band and the subcutaneous port components were removed and replaced in the same encounter.
For covered laparoscopic restrictive procedures that require port replacement, bill CPT code 43771, 43772, or 43773.
Follow the LCD L33411 reasonable and necessary requirements for surgical management of morbid obesity when determining coverage.
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.

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

FIRST_COAST-L33411, Surgical Management of Morbid Obesity

A57145, Billing and Coding: Surgical Management of Morbid Obesity

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

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

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

NOVITAS-JH-L35022, Bariatric Surgical Management of Morbid Obesity

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

A56422, Billing and Coding: Bariatric Surgical Management of Morbid Obesity

NOVITAS-JL-L35022, Bariatric Surgical Management of Morbid Obesity

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

`M16.10`, Unilateral primary osteoarthritis, unspecified hip

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

M16.10, Unilateral primary osteoarthritis, unspecified hip

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

`M16.10`, Unilateral primary osteoarthritis, unspecified hip