Does M40.202 require prior authorization?

No, M40.202 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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`M40.202`, Unspecified kyphosis, cervical region

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 medical record must document medical necessity including relevant history, physical examination, and results of pertinent diagnostic tests or procedures.
A hard copy computer-generated recording of the test results and the provider's interpretation must be included in the patient's record.
The somatosensory evoked potential (SEP) report must specify which nerves were tested, latencies at various testing points, and an evaluation stating whether values are normal or abnormal.

Acceptable evidence of training includes accredited residency/fellowship in the specialty, certification by a nationally recognized organization, or accredited post-graduate courses covering anatomy, neurophysiology and electrodiagnostics; comprehensive AMA/AOA Category 1 CME from a US-accredited institution is acceptable if clearly documented.

Key Coverage Criteria

Somatosensory testing is covered when medically reasonable and necessary and documented in the patient's medical record (relevant history, physical exam, and pertinent diagnostic test results).
Testing and interpretation are covered when ordered and/or furnished by qualified personnel who have documented training and experience in evoked potentials and electrodiagnostics per CMS guidance (accredited residency/fellowship, national certification, or accredited post-graduate training/AMA-AOA Category 1 CME).
The technical component may be furnished by a physical therapist with ABPTS certification without physician supervision, or by a certified technician under supervision consistent with the MPFSDB supervision level assigned to the CPT code (e.g., Level 21 for CPT 95925, 92526, 95927, 95938).
Intraoperative neurophysiological testing is billable only when coverage criteria and medical necessity in related LCD L34623 are met.
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.
Cervical fusion and related cervical spine fusion procedures are the only procedures covered under this policy; other joint or non-cervical spinal procedures (e.g., facet, sacroiliitis, epidural) are not covered by this policy.

20 Active Policies

CGS-J15-L35906, Somatosensory Testing

J15

CGS-J15-L39741, Cervical Fusion

J15

CGS-J18-L35906, Somatosensory Testing

J18

CGS-J18-L39741, Cervical Fusion

J18

A57597, Billing and Coding: Somatosensory Testing

A57604, Billing and Coding: Intraoperative Neurophysiological Testing

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

WPS-J5-L34623, Intraoperative Neurophysiological Testing

WPS-J5-L34624, Somatosensory Testing

WPS-J5-L39788, Cervical Fusion

A59664, Billing and Coding: Cervical Fusion

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NGS-J6-L39770, Cervical Fusion

A59632, Billing and Coding: Cervical Fusion

WPS-J8-L34624, Somatosensory Testing

WPS-J8-L39788, Cervical Fusion

WPS-J8-L34623, Intraoperative Neurophysiological Testing

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

A59674, Billing and Coding: Cervical Fusion

FIRST_COAST-L39799, Cervical Fusion

`M40.202`, Unspecified kyphosis, cervical region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M40.202, Unspecified kyphosis, cervical region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M40.202`, Unspecified kyphosis, cervical region