Does M48.061 require prior authorization?

No, M48.061 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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`M48.061`, Spinal stenosis, lumbar region without neurogenic claudication

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

All documentation must be maintained in the patient's medical record, be legible, include patient identifiers and dates of service, and be made available to the contractor upon request.
The medical record must include the legible signature of the physician or non-physician practitioner responsible for the care and the submitted records must support the selected ICD-10-CM and CPT/HCPCS codes.
Procedural reports for SNRBs and TFESIs must document indications, medical necessity, and baseline pain score; SNRBs must also document percent pain relief achieved immediately after the injection.

Key Coverage Criteria

Epidural steroid injections (ESIs) for pain management are covered when reasonable and necessary per Local Coverage Determination L33906.
Epidural injection CPT codes 62321, 62323, 64479, 64480, 64483 or 64484 used for postoperative acute post-thoracotomy pain (G89.12) or other acute postprocedural pain (G89.18) are exempt from the LCD diagnosis-code restrictions.
Epidural injection CPT 62323 used as part of an implantable infusion pump trial for severe spasticity is adjudicated under NCD 280.14 and is exempt from the diagnosis-code restrictions in this article.
Epidural injection CPT 62323 used for cerebrospinal fluid flow imaging (cisternography CPT 78630) is exempt from the diagnosis-code restrictions and should be billed on the same claim.
Diagnostic selective nerve root blocks (DSNRBs) are coded identically to epidural injections and when performed on a transforaminal level (TFESI CPT 64479, 64480, 64483, 64484) the -KX modifier must be appended to distinguish DSNRB from therapeutic epidural injection.
For covered laparoscopic restrictive procedures that require port replacement, bill CPT code 43771, 43772, or 43773.

20 Active Policies

CGS-J15-L35906, Somatosensory Testing

J15

CGS-J15-L35897, Nerve Conduction Studies and Electromyography

J15

CGS-J18-L35897, Nerve Conduction Studies and Electromyography

J18

CGS-J18-L35906, Somatosensory Testing

J18

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

A59553, Billing and Coding: Trigger Point Injections

A57478, Billing and Coding: Nerve Conduction Studies and Electromyography

A57597, Billing and Coding: Somatosensory Testing

WPS-J5-L34594, Nerve Conduction Studies and Electromyography

WPS-J5-L34624, Somatosensory Testing

A58893, 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

A59487, Billing and Coding: Trigger Point Injections (TPI)

WPS-J8-L34624, Somatosensory Testing

WPS-J8-L34594, Nerve Conduction Studies and Electromyography

FIRST_COAST-L33411, Surgical Management of Morbid Obesity

A56651, Billing and Coding: Epidural Steroid Injections for Pain Management

A57145, Billing and Coding: Surgical Management of Morbid Obesity

FIRST_COAST-L39799, Cervical Fusion

`M48.061`, Spinal stenosis, lumbar region without neurogenic claudication

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M48.061, Spinal stenosis, lumbar region without neurogenic claudication

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M48.061`, Spinal stenosis, lumbar region without neurogenic claudication