Does M48.11 require prior authorization?

No, M48.11 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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`M48.11`, Ankylosing hyperostosis [Forestier], occipito-atlanto-axial 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

Claims must report the precise level(s) of subluxation as the primary diagnosis and the neuromusculoskeletal condition necessitating treatment as the secondary diagnosis.
Each claim must include date of initiation of the course of treatment, symptom/secondary diagnosis code(s), subluxation/primary diagnosis code(s), date of service, place of service, and procedure code; missing items may cause denial or delay.
Diagnosis codes supporting medical necessity must be submitted with each claim; progress notes need not accompany each claim but must be maintained and available upon request.

Key Coverage Criteria

Medicare covers manual manipulation of the spine (chiropractic manipulative treatment) for treatment of spinal subluxation using CPT codes 98940, 98941, or 98942 when medically necessary.
Subluxation must be demonstrated and documented (by x-ray or physician/chiropractic exam) with the problem/complaint addressed and the precise level of each subluxation treated specified in the medical record.
Active/corrective treatment for acute or chronic subluxation requires use of the AT modifier on claims.
Clinical findings supporting subluxation should follow PART elements (Pain, Asymmetry/misalignment, Range of motion abnormality, Tissue/tone changes) documented by observation, palpation, imaging, or measurement as appropriate.
Automated nerve conduction testing using the NC-stat (CPT 95905) is allowed only when there is a high pre-test or prior probability of carpal tunnel syndrome and the claim uses diagnosis code G56.01 or G56.02; allowed one service per arm.
If authorized by state law, physical therapists (PTs) are allowed to perform the technical and professional components of nerve conduction studies represented by CPT codes 95907-95913 consistent with a 7A supervision designation (effective 01/01/2013).

20 Active Policies

CGS-J15-L35897, Nerve Conduction Studies and Electromyography

J15

CGS-J18-L35897, Nerve Conduction Studies and Electromyography

J18

A57478, Billing and Coding: Nerve Conduction Studies and Electromyography

WPS-J5-L34594, Nerve Conduction Studies and Electromyography

WPS-J5-L35486, Pelvic Floor Dysfunction: Anorectal Manometry and EMG

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

A57595, Billing and Coding: Pelvic Floor Dysfunction: Anorectal Manometry and EMG

NGS-J6-L35098, Nerve Conduction Studies and Electromyography

A57668, Billing and Coding: Nerve Conduction Studies and Electromyography

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

WPS-J8-L34594, Nerve Conduction Studies and Electromyography

WPS-J8-L35486, Pelvic Floor Dysfunction: Anorectal Manometry and EMG

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

NGS-JK-L35098, Nerve Conduction Studies and Electromyography

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

A57204, Billing and Coding: MRI and CT Scans of the Head and Neck

A57307, Billing and Coding: Nerve Conduction Studies and Electromyography

A56695, Billing and Coding: Implantable Infusion Pump

A56619, Billing and Coding: Nerve Conduction Studies and Electromyography

A56273, Billing and Coding: Chiropractic Services

`M48.11`, Ankylosing hyperostosis [Forestier], occipito-atlanto-axial region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M48.11, Ankylosing hyperostosis [Forestier], occipito-atlanto-axial region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M48.11`, Ankylosing hyperostosis [Forestier], occipito-atlanto-axial region