Does M48.34 require prior authorization?

No, M48.34 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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`M48.34`, Traumatic spondylopathy, thoracic 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

When billing J7999-KD, enter the name and total dose (mg or mcg) of each drug in Box 19 of the CMS-1500 or the appropriate electronic comment loop; if Box 19 cannot accommodate all information, attach the details to the paper claim.
If a portion of a single-dose vial is not used, submit the HCPCS code for the drug on a separate claim line and append modifier JW to indicate discarded/unused portion.
Separate payment may be made for pump refilling and/or adjustments; submit these services using the appropriate drug refill or maintenance CPT/HCPCS code that accurately describes the service rendered.
Compounded drugs are priced by the A/B MAC contractor by multiplying the contractor's price per mcg or mg by the total number of mcg or mg of each drug used; a pharmacy compounding fee may be allowed in addition to the calculated drug amount.

Key Coverage Criteria

Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.
True off-the-shelf (non‑compounded) drugs used without compounding and administered via DME may be billed using the drug-specific HCPCS code and are reimbursed under CMS ASP methodology.
If Prialt® is implanted as a single agent in the pump, bill using HCPCS code J2278-KD.
Compounded single-agent or combination drug formulations used in implanted infusion pumps must be billed using HCPCS code J7999-KD for reimbursement.
NC-stat® System (alone) is allowed when the beneficiary has a high pre-test probability or prior probability of Carpal Tunnel Syndrome, using CPT 95905.
Allow one NC‑stat® System service per arm (i.e., maximum one service billed with CPT 95905 per arm) for the indicated Carpal Tunnel Syndrome diagnosis.

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

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Providers who document use of an off-the-shelf product without compounding may continue to bill using the drug-specific HCPCS code when appropriate.

Use the listed CPT/HCPCS codes when billing for opioid drugs or procedures related to implantable pumps for chronic intractable pain: J7999-KD, E0782, E0783, E0785, E0786, J2274 (example), J2278-KD, 62327, 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 62369, 62370, 95990, 95991.

, Pelvic Floor Dysfunction: Anorectal Manometry and EMG

WPS-J5-L38213, Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)

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

A57630, Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)

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

A57668, Billing and Coding: Nerve Conduction Studies and Electromyography

NGS-J6-L35098, 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-L35486, Pelvic Floor Dysfunction: Anorectal Manometry and EMG

WPS-J8-L34594, Nerve Conduction Studies and Electromyography

WPS-J8-L38213, Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)

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

A57307, Billing and Coding: Nerve Conduction Studies and Electromyography

A56695, Billing and Coding: Implantable Infusion Pump

M48.34, Traumatic spondylopathy, thoracic region