Does M16.11 require prior authorization?

No, M16.11 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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`M16.11`, Unilateral primary osteoarthritis, right 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 must be submitted in accordance with CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 32 Section 150 (Billing Requirements for Bariatric Surgery for Morbid Obesity), including use of the procedure and diagnosis codes listed there and in this local article.
Coverage for Type II diabetes mellitus complication diagnosis codes is based on the Internet Only Manual (IOM); include documentation and citations required by IOM when billing these diagnoses.
Bariatric surgery claims must reference the applicable national coverage determination (CMS Pub 100-03 Chapter 1 Part 2 Section 100.1) when submitting for payment.

Key Coverage Criteria

Bariatric surgery for treatment of co-morbid conditions related to morbid obesity is payable when billed in accordance with CMS Pub 100-03 Medicare National Coverage Determinations Manual, Chapter 1 Part 2 Section 100.1.
Additional diagnoses listed in this local coverage article for Part A procedure codes and the article's listed CPT codes are covered for bariatric surgery to treat co-morbid conditions related to morbid obesity.
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.
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.

20 Active Policies

CGS-J15-L40232, Total Joint Arthroplasty

J15

CGS-J18-L40232, Total Joint Arthroplasty

J18

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

A54923, Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity

A59811, Billing and Coding: Total Joint Arthroplasty

WPS-J5-L39911, Total Joint Arthroplasty

NGS-J6-L40334, Erythropoiesis Stimulating Agents

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

NGS-J6-L40333, Erythropoiesis Stimulating Agents

WPS-J8-L39911, Total Joint Arthroplasty

A57145, Billing and Coding: Surgical Management of Morbid Obesity

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

FIRST_COAST-L33618, 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-L33411, Surgical Management of Morbid Obesity

NOVITAS-JH-L36007, Lower Extremity Major Joint Replacement (Hip and Knee)

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

NGS-JK-L40334, Erythropoiesis Stimulating Agents

NGS-JK-L40333, Erythropoiesis Stimulating Agents

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

`M16.11`, Unilateral primary osteoarthritis, right hip

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M16.11, Unilateral primary osteoarthritis, right hip

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M16.11`, Unilateral primary osteoarthritis, right hip