Does M46.90 require prior authorization?

No, M46.90 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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`M46.90`, Unspecified inflammatory spondylopathy, 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

Claims must report the appropriate CPT code for the flow cytometry service, include 1 unit of service (UOS), and list the appropriate ICD-10-CM diagnosis code.
Medical necessity documentation per LCD L34513 is required when coverage criteria are not fully met in this billing guideline (for example, when >24 markers are requested).
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim.

The patient's medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.

When using an Advance Beneficiary Notice of Non‑coverage (ABN) with modifier GA, the ABN Form CMS‑R‑131 must be signed by the beneficiary (or properly witnessed if refused) and Part A MAC claims require occurrence code 32 plus the ABN date.

Key Coverage Criteria

Coverage and medical necessity determinations for flow cytometry are governed by Local Coverage Determination L34513.
Flow cytometry may be used to analyze cellular components of body fluids and lymphoreticular tissues, including peripheral blood, cerebrospinal fluid (CSF), bone marrow, lymph nodes, tonsil, spleen, and fine needle aspirate material.
Peripheral blood or fine needle aspirate specimens may be used to avoid more invasive diagnostic procedures when clinically appropriate.
CPT 88182 reports the physician professional and facility technical components of DNA ploidy and S-phase analysis of tumor by flow cytometry.
CPT 88184 (first marker) and CPT 88185 (each additional marker) report the facility technical component of flow cytometric immunophenotyping for assessment of potential hematolymphoid neoplasia.
Flow cytometry interpretation is reported using CPT codes 88187–88189 (one interpretation code per specimen).

11 Active Policies

CGS-J15-L34037, Flow Cytometry

J15

CGS-J18-L34037, Flow Cytometry

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

A59766, 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

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

A57689, Billing and Coding: Lab: Flow Cytometry

A56464, Billing and Coding: Flow Cytometry

A55717, Billing and Coding: Lab: Flow Cytometry

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M46.90, Unspecified inflammatory spondylopathy, site unspecified