Does M16.6 require prior authorization?

No, M16.6 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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`M16.6`, Other bilateral secondary osteoarthritis of 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.
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.

20 Active Policies

CGS-J15-L40232, Total Joint Arthroplasty

J15

CGS-J18-L40232, Total Joint Arthroplasty

J18

WPS-J5-L39911, Total Joint Arthroplasty

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

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

NGS-J6-L40333, Erythropoiesis Stimulating Agents

NGS-J6-L40334, Erythropoiesis Stimulating Agents

WPS-J8-L39911, Total Joint Arthroplasty

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

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

A57145, Billing and Coding: Surgical Management of Morbid Obesity

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

FIRST_COAST-L33411, Surgical Management of Morbid Obesity

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

NGS-JK-L40333, Erythropoiesis Stimulating Agents

NGS-JK-L40334, Erythropoiesis Stimulating Agents

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

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

`M16.6`, Other bilateral secondary osteoarthritis of hip

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M16.6, Other bilateral secondary osteoarthritis of hip

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M16.6`, Other bilateral secondary osteoarthritis of hip