Does M43.28 require prior authorization?

No, M43.28 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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`M43.28`, Fusion of spine, sacral and sacrococcygeal 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

Claims must be submitted in accordance with CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 32 Section 150 (Billing Requirements for Bariatric Surgery for Morbid Obesity), including use of the procedure and diagnosis codes listed there and in this local article.
Coverage for Type II diabetes mellitus complication diagnosis codes is based on the Internet Only Manual (IOM); include documentation and citations required by IOM when billing these diagnoses.
Bariatric surgery claims must reference the applicable national coverage determination (CMS Pub 100-03 Chapter 1 Part 2 Section 100.1) when submitting for payment.

Key Coverage Criteria

Bariatric surgery for treatment of co-morbid conditions related to morbid obesity is payable when billed in accordance with CMS Pub 100-03 Medicare National Coverage Determinations Manual, Chapter 1 Part 2 Section 100.1.
Additional diagnoses listed in this local coverage article for Part A procedure codes and the article's listed CPT codes are covered for bariatric surgery to treat co-morbid conditions related to morbid obesity.
Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.
True off-the-shelf (non‑compounded) drugs used without compounding and administered via DME may be billed using the drug-specific HCPCS code and are reimbursed under CMS ASP methodology.
If Prialt® is implanted as a single agent in the pump, bill using HCPCS code J2278-KD.
Compounded single-agent or combination drug formulations used in implanted infusion pumps must be billed using HCPCS code J7999-KD for reimbursement.

20 Active Policies

CGS-J15-L39802, Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)

J15

CGS-J15-L39383, Sacroiliac Joint Injections and Procedures

J15

CGS-J18-L39383, Sacroiliac Joint Injections and Procedures

J18

CGS-J18-L39802, Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)

J18

A59257, Billing and Coding: Sacroiliac Joint Injections and Procedures

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

A54923, Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity

WPS-J5-L39475, Sacroiliac Joint Injections and Procedures

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

NGS-J6-L36406, Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint

NGS-J6-L39455, Sacroiliac Joint Injections and Procedures

A59233, Billing and Coding: Sacroiliac Joint Injections and Procedures

A57431, Billing and Coding: Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint

WPS-J8-L39475, Sacroiliac Joint Injections and Procedures

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

NGS-JK-L39455, Sacroiliac Joint Injections and Procedures

NGS-JK-L36406, Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint

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

A56695, Billing and Coding: Implantable Infusion Pump

A56852, Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity

`M43.28`, Fusion of spine, sacral and sacrococcygeal region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

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M43.28, Fusion of spine, sacral and sacrococcygeal region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M43.28`, Fusion of spine, sacral and sacrococcygeal region