Does M43.01 require prior authorization?

No, M43.01 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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`M43.01`, Spondylolysis, occipito-atlanto-axial 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.

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.
Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.

20 Active Policies

CGS-J15-L35897, Nerve Conduction Studies and Electromyography

J15

CGS-J18-L35897, Nerve Conduction Studies and Electromyography

J18

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

A57478, Billing and Coding: Nerve Conduction Studies and Electromyography

WPS-J5-L34594, Nerve Conduction Studies and Electromyography

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

A57668, Billing and Coding: Nerve Conduction Studies and Electromyography

NGS-J6-L35098, Nerve Conduction Studies and Electromyography

WPS-J8-L34594, Nerve Conduction Studies and Electromyography

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

NOVITAS-JH-L35003, Intraoperative Neurophysiological Testing

NOVITAS-JH-L34975, Neurophysiology Evoked Potentials (NEPs)

NGS-JK-L35098, Nerve Conduction Studies and Electromyography

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NOVITAS-JL-L34975, Neurophysiology Evoked Potentials (NEPs)

NOVITAS-JL-L35003, Intraoperative Neurophysiological Testing

A56722, Billing and Coding: Intraoperative Neurophysiological Testing

A56773, Billing and Coding: Neurophysiology Evoked Potentials (NEPs)

A57307, Billing and Coding: Nerve Conduction Studies and Electromyography

A57206, Billing and Coding: Lumbar MRI

`M43.01`, Spondylolysis, occipito-atlanto-axial region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M43.01, Spondylolysis, occipito-atlanto-axial region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M43.01`, Spondylolysis, occipito-atlanto-axial region