Does M47.895 require prior authorization?

No, M47.895 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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`M47.895`, Other spondylosis, thoracolumbar 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

The medical record must document medical necessity including relevant history, physical examination, and results of pertinent diagnostic tests or procedures.
A hard copy computer-generated recording of the test results and the provider's interpretation must be included in the patient's record.
The somatosensory evoked potential (SEP) report must specify which nerves were tested, latencies at various testing points, and an evaluation stating whether values are normal or abnormal.

Acceptable evidence of training includes accredited residency/fellowship in the specialty, certification by a nationally recognized organization, or accredited post-graduate courses covering anatomy, neurophysiology and electrodiagnostics; comprehensive AMA/AOA Category 1 CME from a US-accredited institution is acceptable if clearly documented.

Key Coverage Criteria

Somatosensory testing is covered when medically reasonable and necessary and documented in the patient's medical record (relevant history, physical exam, and pertinent diagnostic test results).
Testing and interpretation are covered when ordered and/or furnished by qualified personnel who have documented training and experience in evoked potentials and electrodiagnostics per CMS guidance (accredited residency/fellowship, national certification, or accredited post-graduate training/AMA-AOA Category 1 CME).
The technical component may be furnished by a physical therapist with ABPTS certification without physician supervision, or by a certified technician under supervision consistent with the MPFSDB supervision level assigned to the CPT code (e.g., Level 21 for CPT 95925, 92526, 95927, 95938).
NC-stat testing (CPT 95905) is allowed when the beneficiary has a high pre-test or prior probability of Carpal Tunnel Syndrome (CTS), limited to one service per arm.
Use CPT 95870 for sampling muscles other than the paraspinals associated with the extremities that have been tested.
Diagnostic or therapeutic paravertebral facet joint injections (CPT 64490-64495) for cervical/thoracic or lumbar/sacral facet-mediated pain are covered when reasonable and necessary and supported by documentation consistent with LCD L33930.

20 Active Policies

CGS-J15-L35906, Somatosensory Testing

J15

CGS-J15-L38773, Facet Joint Interventions for Pain Management

J15

CGS-J18-L38773, Facet Joint Interventions for Pain Management

J18

CGS-J18-L35906, Somatosensory Testing

J18

WPS-J5-L38841, Facet Joint Interventions for Pain Management

A58477, Billing and Coding: Facet Joint Interventions for Pain Management

WPS-J5-L34624, Somatosensory Testing

A57597, Billing and Coding: Somatosensory Testing

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

NGS-J6-L35098, Nerve Conduction Studies and Electromyography

A57668, Billing and Coding: Nerve Conduction Studies and Electromyography

A57826, Billing and Coding: Facet Joint Interventions for Pain Management

NGS-J6-L35936, Facet Joint Interventions for Pain Management

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

WPS-J8-L38841, Facet Joint Interventions for Pain Management

WPS-J8-L34624, Somatosensory Testing

FIRST_COAST-L33930, Facet Joint Interventions for Pain Management

FIRST_COAST-L40404, Facet Joint Interventions for Pain Management

A57787, Billing and Coding: Facet Joint Interventions for Pain Management

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

`M47.895`, Other spondylosis, thoracolumbar region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M47.895, Other spondylosis, thoracolumbar region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M47.895`, Other spondylosis, thoracolumbar region