Does M19.011 require prior authorization?

No, M19.011 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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`M19.011`, Primary osteoarthritis, right shoulder

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

The medical record must document relevant medical history, physical examination, pertinent diagnostic test/procedure results, and history of pharmacologic therapy supporting medical necessity.
Documentation for subsequent courses must clearly establish reduction in patient symptomatology and medication usage and must be available upon request.
Append appropriate site modifier (RT or LT) to CPT 20610/20611 for unilateral services and modifier 50 to indicate bilateral services.

Key Coverage Criteria

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.
Occupational therapy is covered for patients with migraine (G43.xx) who require training to reduce pain during basic and instrumental activities of daily living, typically completed in 3–4 sessions.
Electrical stimulation (attended CPT 97032 or unattended HCPCS G0283) may be covered as part of a therapy plan of care to improve function when the nerve supply to the muscle is intact and atrophy is due to non-neurological disuse (e.g., post-casting, splinting, soft-tissue scarring).
Wheelchair management training (CPT 97542) is covered for patient and/or caregiver training in transfers and propulsion when documentation ties the training to attainable functional goals.
Therapeutic exercise (CPT 97110) is covered when used to address impairments of exercise tolerance due to cardiopulmonary impairments.

17 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

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

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

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

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

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

A57311, Billing and Coding: Physical Therapy - Home Health

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

A59878, Billing and Coding: Total Shoulder Arthroplasty

AETNA-CPB-0207, Prolotherapy and Sclerotherapy

A53057, Billing and Coding: Home Health Occupational Therapy

A53058, Billing and Coding: Home Health Physical Therapy

A53064, Billing and Coding: Outpatient Occupational Therapy

A53065, Billing and Coding: Outpatient Physical Therapy

A56619, Billing and Coding: Nerve Conduction Studies and Electromyography

`M19.011`, Primary osteoarthritis, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

M19.011, Primary osteoarthritis, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

`M19.011`, Primary osteoarthritis, right shoulder