Does M19.09 require prior authorization?

No, M19.09 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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`M19.09`, Primary osteoarthritis, other specified site

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

Patient record must document BMI >= 35, at least one obesity-related comorbidity, and a primary diagnosis of morbid obesity (ICD-10-CM E66.01) for bariatric surgery claims.
Documentation of prior conservative medical treatment: active participation within the 12 months prior to surgery in a physician- or healthcare professional-supervised weight-management program for a minimum of four consecutive months with monthly documentation of weight and BMI, current dietary regimen, and physical activity.
A thorough multidisciplinary evaluation within the previous 6 months must include: (a) surgeon evaluation recommending the procedure and describing the proposed procedure, (b) separate non-surgeon physician medical evaluation with recommendation and medical clearance, (c) mental health/psychosocial clearance including a statement on motivation and ability to follow post-surgical requirements, and (d) nutritional evaluation by a physician or registered dietician.

Key Coverage Criteria

Roux-en-Y gastric bypass (RYGBP) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Laparoscopic adjustable gastric banding (AGB) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Laparoscopic sleeve gastrectomy is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
CPT 97110 may be billed when treating impairments of exercise tolerance due to cardiopulmonary impairments.
CPT 97542 (wheelchair management training) may be billed for wheelchair propulsion training when the training is tied to expected functional goals attainable by the patient or caregiver.

20 Active Policies

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

A59915, Billing and Coding: Pharmacogenomic Testing

NGS-J6-L39995, Pharmacogenomic Testing

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

FIRST_COAST-L39073, Pharmacogenomics Testing

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

A58812, Billing and Coding: Pharmacogenomics Testing

NOVITAS-JH-L39063, Pharmacogenomics Testing

NGS-JK-L39995, Pharmacogenomic Testing

NOVITAS-JL-L39063, Pharmacogenomics Testing

A58801, Billing and Coding: Pharmacogenomics Testing

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

A56619, Billing and Coding: Nerve Conduction Studies and Electromyography

A56852, Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity

A53026, Billing and Coding: Bariatric Surgery Coverage

A53058, Billing and Coding: Home Health Physical Therapy

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

ANTHEM-GL-A051149, CPT

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

`M19.09`, Primary osteoarthritis, other specified site

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M19.09, Primary osteoarthritis, other specified site

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M19.09`, Primary osteoarthritis, other specified site