Does M53.1 require prior authorization?

No, M53.1 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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`M53.1`, Cervicobrachial syndrome

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 NCSs and NEMG are performed on the same day for the same patient they must be reported on the same claim.
When billing non-covered services/tests report unlisted neurological CPT 95999 and provide a description of the service/test in block 80 (Part A) or box 19 (Part B) or electronic equivalent; failure to include this information will result in Part A claims being returned and Part B claims rejected.
All documentation must be maintained in the patient's medical record, be legible, include patient identification and dates of service, and include the legible signature of the responsible physician or non-physician practitioner.
The submitted medical record must support the selected ICD-10-CM code(s), the submitted CPT/HCPCS code must describe the service performed, and the record must clearly document the medical necessity, the indication for ordering the test(s), and a clear diagnostic impression.

Key Coverage Criteria

Nerve conduction studies (NCS) without needle electromyography (NEMG) are allowed for individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome when one of the diagnosis codes G56.01, G56.02, G56.03, G56.11, G56.12, G56.13, G56.21, G56.22, G56.23, G57.51, G57.52, or G57.53 is reported.
NCS without NEMG is allowed for individuals with significant lymphedema in the affected extremity when diagnosis code I89.0 is reported in addition to the primary diagnosis.
NCS without NEMG is allowed for individuals treated with anticoagulants when diagnosis code Z79.01 or Z79.02 is reported in addition to the primary diagnosis.
Services that meet the Medicare reasonable and necessary requirements per Local Coverage Determination (LCD) L35090 are covered when billed as reconstructive or medically necessary procedures.
Dermabrasion for treatment of rhinophyma is covered when the medical record documents the beneficiary's rhinophyma disease process supporting medical necessity.
Abdominal lipectomy/panniculectomy is covered when the pannus causes chronic intertrigo (skin irritation, infection, or chafing) and there is documented functional impairment (e.g., difficulty walking, exercising, or activities of daily living) after conservative treatment.

20 Active Policies

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

A57123, Billing and Coding: Nerve Conduction Studies and Electromyography

FIRST_COAST-L34859, Nerve Conduction Studies and Electromyography

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M53.1, Cervicobrachial syndrome