Does M25.269 require prior authorization?

No, M25.269 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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`M25.269`, Flail joint, unspecified 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

All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
Every page of the medical record must be legible and include appropriate patient identification information such as complete name and dates of service.
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the patient’s care.
The submitted medical record must support the use of the selected ICD-10-CM code(s).

Key Coverage Criteria

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.
Simultaneous bilateral hip or knee replacement during the same encounter is covered when medical necessity for bilateral procedure is documented; bilateral procedures are subject to bilateral pricing.
Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is covered for advanced joint disease when arthritis of the hip or knee is supported by X-ray or MRI demonstrating subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis.
THA or TKA is covered when the patient has pain or functional disability at the hip or knee, e.g., pain interfering with activities of daily living (ADLs), pain increased with initiation of activity, or pain increased with weight bearing.
THA or TKA is covered when there is documentation of unsuccessful conservative therapy appropriate to the episode of care, generally a reasonable attempt of usually 3 months or more (e.g., trial of NSAIDs or supervised physical therapy, or documented contraindication to such therapy).
THA or TKA is covered for other LCD-indicated causes when appropriate supporting evidence is documented, e.g., malignancy of the joint supported by pathology and oncology referral, or fracture supported by X-ray.

13 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

A57765, Billing and Coding: Major Joint Replacement (Hip and Knee)

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

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M25.269, Flail joint, unspecified knee