Does M43.8X9 require prior authorization?

No, M43.8X9 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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`M43.8X9`, Other specified deforming dorsopathies, site unspecified

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

Patient record must document BMI >= 35, at least one obesity-related comorbidity, and a primary diagnosis of morbid obesity (ICD-10-CM E66.01) for bariatric surgery claims.
Documentation of prior conservative medical treatment: active participation within the 12 months prior to surgery in a physician- or healthcare professional-supervised weight-management program for a minimum of four consecutive months with monthly documentation of weight and BMI, current dietary regimen, and physical activity.
A thorough multidisciplinary evaluation within the previous 6 months must include: (a) surgeon evaluation recommending the procedure and describing the proposed procedure, (b) separate non-surgeon physician medical evaluation with recommendation and medical clearance, (c) mental health/psychosocial clearance including a statement on motivation and ability to follow post-surgical requirements, and (d) nutritional evaluation by a physician or registered dietician.

Key Coverage Criteria

Roux-en-Y gastric bypass (RYGBP) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Laparoscopic adjustable gastric banding (AGB) is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
Laparoscopic sleeve gastrectomy is covered when the beneficiary has BMI >= 35 and at least one obesity-related comorbidity, has documented failure of reasonable non-invasive/non-surgical treatments with compliance, and has completed the required multidisciplinary evaluation within the previous 6 months.
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.

13 Active Policies

CGS-J15-L35906, Somatosensory Testing

J15

CGS-J18-L35906, Somatosensory Testing

J18

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

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

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

NOVITAS-JH-L35003, Intraoperative Neurophysiological Testing

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

NOVITAS-JL-L35003, Intraoperative Neurophysiological Testing

A56722, Billing and Coding: Intraoperative Neurophysiological Testing

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A57041, Billing and Coding: Somatosensory Testing

A53026, Billing and Coding: Bariatric Surgery Coverage

`M43.8X9`, Other specified deforming dorsopathies, site unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

M43.8X9, Other specified deforming dorsopathies, site unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

`M43.8X9`, Other specified deforming dorsopathies, site unspecified