Does M43.13 require prior authorization?

No, M43.13 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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`M43.13`, Spondylolisthesis, cervicothoracic 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.

Neuromuscular junction studies (CPT 95937) reports must document stimulation rate and any significant incremental or decremental responses and may be reported separately from motor/sensory NCS of the same nerves.

When testing exceeds the reasonable maximum numbers listed in the guidance table, the provider must supply supplementary documentation justifying the additional tests; documentation must also justify testing an asymptomatic contralateral limb for normative values.

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, Nerve Conduction Studies and Electromyography

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

WPS-J5-L39788, Cervical Fusion

A59664, Billing and Coding: Cervical Fusion

A57478, Billing and Coding: Nerve Conduction Studies and Electromyography

A57668, Billing and Coding: Nerve Conduction Studies and Electromyography

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

A59632, Billing and Coding: Cervical Fusion

NGS-J6-L39770, Cervical Fusion

NGS-J6-L35098, Nerve Conduction Studies and Electromyography

WPS-J8-L39788, Cervical Fusion

WPS-J8-L34594, Nerve Conduction Studies and Electromyography

A59674, Billing and Coding: Cervical Fusion

FIRST_COAST-L39799, Cervical Fusion

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

NOVITAS-JH-L39793, Cervical Fusion

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M43.13, Spondylolisthesis, cervicothoracic region