Does M53.3 require prior authorization?

No, M53.3 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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`M53.3`, Sacrococcygeal disorders, not elsewhere classified

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

The patient's medical record must contain documentation that fully supports medical necessity for services included within the related LCD, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Medical record documentation must be available to Medicare upon request.
The performing provider must maintain medical record documentation that clearly supports the medical necessity of the billed service and include that documentation in the patient's record for review upon request.

Key Coverage Criteria

Minimally-invasive surgical fusion of the sacroiliac (SI) joint is covered when the patient's medical record documents medical necessity per the related Local Coverage Determination (LCD), including relevant history, physical exam, and diagnostic test results supporting the procedure.
CPT codes 64400-64530 for peripheral nerve blocks may be reported on the date of surgery when performed for postoperative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection, or epidural injection and the adequacy of intraoperative anesthesia is not dependent on the peripheral nerve block.
Peripheral nerve block services that are separate, medically necessary services which cannot be rendered by the surgeon may be reported if the surgeon documents the reason for referral and the additional services are justified in the medical record.
Coverage for percutaneous minimally invasive fusion/stabilization of the sacroiliac joint is determined by the related Local Coverage Determination L36000 and only covered when that LCD's clinical indications are met.
Coverage for amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications is determined by Local Coverage Determination L39139; consult LCD L39139 for specific clinical indications and thresholds.
Diagnostic sacroiliac joint injection(s) (CPT 27096 and/or 64451) to confirm sacroiliac joint–mediated pain; may be performed unilateral or bilateral.

20 Active Policies

CGS-J15-L39802, Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)

J15

CGS-J15-L39383, Sacroiliac Joint Injections and Procedures

J15

CGS-J18-L39802, Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ)

J18

CGS-J18-L39383, Sacroiliac Joint Injections and Procedures

J18

WPS-J5-L39475, Sacroiliac Joint Injections and Procedures

WPS-J5-L36000, Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain

A59257, Billing and Coding: Sacroiliac Joint Injections and Procedures

A57596, Billing and Coding: Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain

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

A57431, Billing and Coding: Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint

NGS-J6-L36850, Peripheral Nerve Blocks

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

NGS-J6-L39455, Sacroiliac Joint Injections and Procedures

A57452, Billing and Coding: Peripheral Nerve Blocks

NGS-J6-L36406, Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint

A59233, Billing and Coding: Sacroiliac Joint Injections and Procedures

WPS-J8-L39475, Sacroiliac Joint Injections and Procedures

WPS-J8-L36000, Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain

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

NGS-JK-L36406, Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint

`M53.3`, Sacrococcygeal disorders, not elsewhere classified

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

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M53.3, Sacrococcygeal disorders, not elsewhere classified

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M53.3`, Sacrococcygeal disorders, not elsewhere classified