Does M25.819 require prior authorization?

No, M25.819 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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`M25.819`, Other specified joint disorders, unspecified 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 article provides billing and coding guidance and references LCD L39116; required documentation (e.g., medical records, prior authorization, specific forms) is not specified here and must be obtained from LCD L39116.
Billing, coding, and documentation requirements (e.g., required medical record elements, coding guidance, prior authorization if applicable) are specified in LCD L39139 and accompanying billing guidance; review LCD L39139 for the exact documentation required for claims.
This billing and coding article provides billing and coding guidance for Local Coverage Determination (LCD) L39575 regarding amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications.

This billing and coding article references Local Coverage Determination LCD L39624 for coverage and documentation requirements for amniotic and placental-derived product injections/applications for musculoskeletal (non-wound) indications; the LCD text was not provided so specific documentation requirements cannot be extracted.

Key Coverage Criteria

No specific clinical indications are provided in this billing and coding article; coverage criteria for amniotic and placental-derived product injections/applications for musculoskeletal non-wound indications are described in Local Coverage Determination L39116.
Coverage for amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications is determined by Local Coverage Determination L39139; consult LCD L39139 for specific clinical indications and thresholds.
Coverage applies when the amniotic or placental-derived product injection/application meets the reasonable and necessary requirements of Local Coverage Determination L39877.
Amniotic and placental-derived product injections/applications are covered only when they meet the reasonable and necessary clinical requirements specified in LCD L39879 (Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound).
OnabotulinumtoxinA (Botox) medically necessary indications (initial approval): Achalasia — Treatment of achalasia when the member has tried and failed or is a poor candidate for conventional therapy such as pneumatic dilation and surgical myotomy.
Botulinum toxin type A has become 1st-line therapy for Frey's syndrome.

7 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

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

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

AETNA-CPB-0113, Botulinum Toxin

`M25.819`, Other specified joint disorders, unspecified shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

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M25.819, Other specified joint disorders, unspecified shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

`M25.819`, Other specified joint disorders, unspecified shoulder