Does M16.9 require prior authorization?

No, M16.9 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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`M16.9`, Osteoarthritis of hip, unspecified

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.
All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.

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.
Coverage for lower extremity major joint replacement (hip and knee) is subject to the reasonable and necessary requirements of Local Coverage Determination L36007; services meeting LCD L36007 criteria are covered.
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.

20 Active Policies

WPS-J5-L39911, Total Joint Arthroplasty

A59811, Billing and Coding: Total Joint Arthroplasty

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

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M16.9, Osteoarthritis of hip, unspecified