Does M40.292 require prior authorization?

No, M40.292 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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`M40.292`, Other 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.
If the performing provider differs from the ordering/referring provider, the performing provider must retain copies of the test results, interpretation, and the ordering/referring provider's order for the studies.

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-L39741, Cervical Fusion

J15

CGS-J15-L35906, Somatosensory Testing

J15

CGS-J18-L35906, Somatosensory Testing

J18

CGS-J18-L39741, Cervical Fusion

J18

A57604, Billing and Coding: Intraoperative Neurophysiological Testing

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M40.292, Other kyphosis, cervical region