Does M48.56XA require prior authorization?

No, M48.56XA 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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`M48.56XA`, Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture

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

This article provides billing and coding guidelines that complement Local Coverage Determination (LCD) L37848 for Lumbar Spinal Fusion; refer to LCD L37848 for clinical medical necessity criteria.
All services ordered or rendered to Medicare beneficiaries must be signed; providers/suppliers must notify beneficiaries in writing prior to rendering the service if aware the test/item/procedure may not be covered.
A valid ICD-10-CM diagnosis code that best describes the patient's condition must be reported on the claim; claims without a valid ICD-10-CM code will be returned as incomplete under Section 1833(e).

Key Coverage Criteria

Bone mass measurement tests are covered when ordered by the treating physician or a qualified non-physician practitioner authorized by state law.
An initial bone mass measurement is covered (Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless of sites studied).
A DXA confirmatory test may be performed and covered as a baseline for future monitoring (exception to the 'one type only' rule).
CPT code 77082 (vertebral fracture assessment) is covered when medically necessary, with symptoms documented and when results are anticipated to be used in patient management.
Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.

16 Active Policies

CGS-J15-L36460, Bone Mass Measurement

J15

CGS-J18-L36460, Bone Mass Measurement

J18

A57604, Billing and Coding: Intraoperative Neurophysiological Testing

WPS-J5-L34623, Intraoperative Neurophysiological Testing

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

WPS-J8-L34623, Intraoperative Neurophysiological Testing

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

A59040, Billing and Coding: Bone Mass Measurement

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

A57132, Billing and Coding: Bone Mass Measurement

A56396, Billing and Coding: Lumbar Spinal Fusion

A57206, Billing and Coding: Lumbar MRI

A57311, Billing and Coding: Physical Therapy - Home Health

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

`M48.56XA`, Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture

Prior Authorization

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

M48.56XA, Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture

Prior Authorization

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

`M48.56XA`, Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture