Does M25.561 require prior authorization?

No, M25.561 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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`M25.561`, Pain in right 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).
An Advance Beneficiary Notice of Noncoverage (ABN) may be used for outpatient services likely to be non-covered; follow CMS Claims Processing Manual Chapter 30 guidance when issuing ABNs.

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.
Nonvascular extremity ultrasound is covered when medical necessity is documented in the patient's record, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Diagnostic nonvascular extremity ultrasound is covered when the claim includes an ICD-10-CM diagnosis code that best describes the patient's condition and the test result or the symptoms prompting the test are documented.
Urine, blood, or oral fluid specimens may be used for drug testing, with urine preferred for broad screening of common drugs.
Medicare Part B will pay for drug screening services when all coverage criteria, limitations, and medical necessity requirements of LCD DL34645 are met.
Claims for drug screening services are payable under Medicare Part B only in these places of service: office (11), urgent care (20), independent clinic (49), federally qualified health center — freestanding (50), rural health clinic — freestanding (72), and independent laboratory (81).

20 Active Policies

CGS-J15-L36029, Urine Drug Testing

J15

CGS-J18-L36029, Urine Drug Testing

J18

WPS-J5-L34645, Urine Drug Testing

A56915, Billing and Coding: Urine Drug Testing

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

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M25.561, Pain in right knee