Does M43.12 require prior authorization?

No, M43.12 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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`M43.12`, Spondylolisthesis, 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

A clinical history from the referral source indicating the need for testing must be available in the medical record and retrievable for review.
If an E/M service is billed as separate and identifiable, medical record must document medical necessity and the E/M CPT code must be billed with modifier 25.
Nerve conduction study reports must include numerical data (amplitude, latency, velocity) and F-wave descriptions must reference corresponding motor conduction data.
Blink reflex (CPT 95933) reports should include bilateral recordings with ipsilateral and contralateral stimulation and note presence or absence of R1 and R2 components.

Key Coverage Criteria

Electrodiagnostic testing (EMG and/or nerve conduction studies) is indicated for evaluation of suspected carpal tunnel syndrome.
EMG and/or nerve conduction studies are indicated for evaluation of suspected radiculopathy.
EMG and/or nerve conduction studies are indicated for evaluation of suspected mononeuropathy (single-nerve entrapment or injury).
EMG and/or nerve conduction studies are indicated for evaluation of suspected polyneuropathy or mononeuropathy multiplex.
EMG is indicated for evaluation of suspected myopathy.
EMG and nerve conduction studies are indicated for evaluation of suspected motor neuropathies (e.g., amyotrophic lateral sclerosis).

20 Active Policies

CGS-J15-L35897, Nerve Conduction Studies and Electromyography

J15

CGS-J15-L39741, Cervical Fusion

J15

CGS-J18-L39741, Cervical Fusion

J18

CGS-J18-L35897, Nerve Conduction Studies and Electromyography

J18

WPS-J5-L34594

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M43.12, Spondylolisthesis, cervical region