Does M46.26 require prior authorization?

No, M46.26 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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`M46.26`, Osteomyelitis of vertebra, lumbar 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

This article provides billing and coding guidelines that complement Local Coverage Determination (LCD) L37848 for Lumbar Spinal Fusion; refer to LCD L37848 for clinical medical necessity criteria.
The patient’s medical record must include the ordering provider’s assessment as it relates to the patient’s complaint for that visit.
Medical records must contain relevant medical history and results of pertinent tests or procedures performed.
For diagnostic tests, report the result of the test if known; otherwise report the symptoms that prompted performing the test.

Key Coverage Criteria

A valid ICD-10-CM diagnosis code that best describes the patient’s condition for which the debridement service was performed must be reported on the claim.
When a service requires a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
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.
Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
No specific clinical indications are provided in this billing and coding article; coverage criteria for amniotic and placental-derived product injections/applications for musculoskeletal non-wound indications are described in Local Coverage Determination L39116.

11 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J18-L34032, Debridement Services

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

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M46.26, Osteomyelitis of vertebra, lumbar region