Does M40.35 require prior authorization?

No, M40.35 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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`M40.35`, Flatback syndrome, thoracolumbar 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

All documentation must be maintained in the patient's medical record and made available to the contractor upon request; every page must be legible and include patient identification and dates of service.
The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing care to the patient.
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.
Refer to LCD L34975 for the detailed reasonable and necessary clinical criteria and documentation required to support coverage of NEPs.

Key Coverage Criteria

Continuous intraoperative neurophysiologic monitoring provided one-on-one in the operating room (CPT 95940) is covered when it supports the covered indications in LCD L35003.
Report continuous intraoperative neurophysiologic monitoring in the operating room (95940) in addition to monitoring services provided from outside the operating room (G0453); coverage includes interpretation of baseline studies and removal of electrodes at the end of the procedure when supporting the LCD indications.
Reimbursement may be made for covered intraoperative monitoring when performed at POS 19, POS 21, POS 22, or POS 24.
Neurophysiology Evoked Potentials (NEPs) — including Somatosensory Evoked Potentials (SEPs), Brainstem Auditory Evoked Potentials (BAEPs/BAERs), and Visual Evoked Potentials (VEPs/VERs) — are covered when determined to be reasonable and necessary in accordance with LCD L34975.
Somatosensory testing is covered when it is medically necessary, ordered by a referring/ordering physician, and the medical record documents relevant history, physical exam, and pertinent diagnostic tests supporting the need for the test.
Diagnostic somatosensory tests should be performed when test results are expected to influence or contribute to the patient’s course of treatment.

20 Active Policies

CGS-J15-L35906, Somatosensory Testing

J15

CGS-J18-L35906, Somatosensory Testing

J18

A57597, Billing and Coding: Somatosensory Testing

A57604, Billing and Coding: Intraoperative Neurophysiological Testing

WPS-J5-L34623

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M40.35, Flatback syndrome, thoracolumbar region