Does M25.869 require prior authorization?

No, M25.869 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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`M25.869`, Other specified joint disorders, 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, be legible, include patient identifiers (e.g., full name, dates of service), and contain the legible signature of the responsible physician or non-physician practitioner.
The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
For advanced joint disease, document arthritis supported by X-ray or MRI that demonstrates at least one specified radiographic finding (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis).

Key Coverage Criteria

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.
Revision TKA or THA for infection is covered when laboratory and/or pathology reports documenting infection, documentation of infection treatment, and a physician note indicating it is appropriate to proceed with surgery are present in the medical record.

11 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

FIRST_COAST-L33618, Major Joint Replacement (Hip and Knee)

A59766, 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-0637, Osteochondral Autografts (Mosaicplasty, OATS)

AETNA-CPB-0786, Menaflex

ANTHEM-SURG.00142, Genicular Procedures for Treatment of Knee Pain

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

`M25.869`, Other specified joint disorders, unspecified knee

Prior Authorization

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

M25.869, Other specified joint disorders, unspecified knee

Prior Authorization

Documentation Required

Key Coverage Criteria

11 Active Policies

Related Codes

Have a follow-up question?

`M25.869`, Other specified joint disorders, unspecified knee