Does M24.572 require prior authorization?

No, M24.572 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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`M24.572`, Contracture, left ankle

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

Specified HCPCS codes require a face-to-face encounter and Written Order Prior to Delivery (WOPD) per Final Rule 1713; failure to obtain WOPD prior to delivery results in denial.
Supplier must include diagnosis code(s) on the claim line for HCPCS L4396, L4397, L4392 and L4631.
For custom-fabricated orthoses, the supplier's records must document medical necessity for a custom device rather than a prefabricated orthosis and be available upon request.
Supplier records must show the product specified by the treating practitioner, the treating practitioner's medical record that justifies the type of product (prefabricated versus custom), and detailed justification for the HCPCS code billed.

Key Coverage Criteria

Ankle-foot orthoses (AFO) and knee-ankle-foot orthoses (KAFO) are covered when they are rigid or semi-rigid devices used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body.
Coverage requires that reasonable and necessary (R&N) medical necessity criteria in the related Local Coverage Determination (LCD) are met for the beneficiary's diagnosis or functional deficit.
An orthosis provided within two days prior to discharge to home is eligible for DME MAC coverage if it is medically necessary after discharge and was not needed for inpatient treatment or rehabilitation.
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.

12 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

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

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

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M24.572, Contracture, left ankle