Does M17.12 require prior authorization?

No, M17.12 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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`M17.12`, Unilateral primary osteoarthritis, left 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

Medicare contractors may require operative notes, reports of standing x-rays, and/or arthroscopy results to define the patient’s knee condition when adjudicating coverage.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A valid ICD-10-CM diagnosis code that best describes the patient's condition must be submitted on the claim; claims without a valid ICD-10-CM code will be returned as incomplete under Section 1833(e).

Key Coverage Criteria

Arthroscopic lavage or arthroscopic debridement for osteoarthritic knee in patients WITHOUT severe osteoarthritis who present with mechanical symptoms (eg, locking, snapping, popping), abnormal limb/knee alignment, or less severe/early degenerative arthritis may be considered for coverage at the discretion of the Medicare contractor.
Intra-articular hyaluronan injections are covered for pain associated with osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics.
Intra-articular hyaluronan injections may be used as a therapeutic option for osteoarthritis of the shoulder.
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.
Intraarticular hyaluronan is covered for treatment of symptomatic osteoarthritis of the knee in patients who have failed to respond adequately for at least 3 months to simple analgesics and conservative nonpharmacologic therapy (exercise/physical therapy, weight loss if appropriate, use of assistive devices).

20 Active Policies

CGS-J15-L40232, Total Joint Arthroplasty

J15

CGS-J18-L40232, Total Joint Arthroplasty

J18

A59811, Billing and Coding: Total Joint Arthroplasty

WPS-J5-L39911, Total Joint Arthroplasty

A56157, Billing and Coding: Intraarticular Knee Injections of Hyaluronan

WPS-J5-L39529, Intraarticular Knee Injections of Hyaluronan

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

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

A52369, Billing and Coding: Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee Medical Policy Article

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

A52420, Billing and Coding: Hyaluronans Intra-articular Injections of

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-L39529, Intraarticular Knee Injections of Hyaluronan

WPS-J8-L39911, Total Joint Arthroplasty

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)

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

`M17.12`, Unilateral primary osteoarthritis, left knee

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M17.12, Unilateral primary osteoarthritis, left knee

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M17.12`, Unilateral primary osteoarthritis, left knee