Does M26.629 require prior authorization?

No, M26.629 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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`M26.629`, Arthralgia of temporomandibular joint, unspecified side

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 identification (e.g., name, dates of service), and be made available to the contractor upon request.
The medical record must include the legible signature of the physician or non-physician practitioner responsible for the care and signed/dated office visit or operative report.
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.

Key Coverage Criteria

Trigger point injections (CPT 20552 or 20553) are covered when medically necessary to treat documented myofascial trigger points causing pain, with procedural documentation supporting medical necessity.
CPT 20552 may be reported for trigger point injections involving 1 or 2 muscles; CPT 20553 may be reported for injections involving 3 or more muscles.
The medication used for the injection must be billed on the same claim as the trigger point administration and reported with the appropriate HCPCS drug J-code or revenue code.
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.
Trigger point injections (CPT 20552, 20553) are covered when they meet the reasonable and necessary clinical requirements and frequency limitations of the referenced LCD L39656.

13 Active Policies

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

A59553, Billing and Coding: Trigger Point Injections

A59487, Billing and Coding: Trigger Point Injections (TPI)

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

A59480, Billing and Coding: Trigger Point Injections (TPI)

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

A59498, Billing and Coding: Trigger Point Injections (TPI)

A57701, Billing and Coding: Trigger Point Injections (TPI)

AETNA-CPB-0784, Blood and Adipose Tissue Derived Products for Selected Indications

ANTHEM-CG-SURG-17, Trigger Point Injections

`M26.629`, Arthralgia of temporomandibular joint, unspecified side

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

M26.629, Arthralgia of temporomandibular joint, unspecified side

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

`M26.629`, Arthralgia of temporomandibular joint, unspecified side