Does M53.81 require prior authorization?

No, M53.81 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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`M53.81`, Other specified dorsopathies, 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

For CPT 97032, document the type of electrical stimulation (including 'manual'/'attended'), area(s) treated, and if used for muscle weakness provide objective strength ratings and functional deficits; if used for pain provide pain rating, pain location, and effect on function.
For HCPCS G0283, document the type of electrical stimulation (e.g., TENS, IFC), area(s) treated, and objective/subjective measures showing impact on pain intensity/location/functional impact and/or swelling.
For non-implantable pelvic floor stimulation, document cognitive intactness, patient motivation, and a failed documented trial of PME training (defined as no clinically significant improvement after 4 weeks of an ordered PME plan).

Key Coverage Criteria

Attended/manual electrical stimulation (CPT 97032) is covered when the qualified professional provides direct 1-on-1 patient contact to apply/manualy adjust stimulation (e.g., direct motor point stimulation, FES/NMES when combined with therapeutic exercise/neuromuscular reeducation/functional activities).
Non-implantable pelvic floor electrical stimulation delivered via vaginal or anal probes (reportable as CPT 97032) is covered for stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
Unattended/supervised electrical stimulation provided as part of a therapy plan of care (HCPCS G0283) is covered for non-wound indications (e.g., TENS, IFC, cyclical muscle stimulation) when used to control pain and/or swelling and when objective/subjective improvement is documented.
Electromagnetic therapy (HCPCS G0329) is covered for chronic stage III and IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.
Unattended electrical stimulation for wound management (HCPCS G0281) is covered for chronic stage III and IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers that have not shown measurable healing after 30 days of conventional care.
Regional or local nerve blocks performed as an adjunct to, or as the sole means of, regional/local anesthesia for an operative procedure are not affected by this noncoverage policy (i.e., such intraoperative regional/local anesthesia is allowed).

20 Active Policies

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

NGS-J6-L36850, Peripheral Nerve Blocks

A57452, Billing and Coding: Peripheral Nerve Blocks

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

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

FIRST_COAST-L33933, Peripheral Nerve Blocks

NGS-JK-L36850, Peripheral Nerve Blocks

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

A56695, Billing and Coding: Implantable Infusion Pump

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

A57221, Billing and Coding: Plastic Surgery

A56607, Billing and Coding: Continuous Peripheral Nerve Blocks (CPNB)

A57788, Billing and Coding: Peripheral Nerve Blocks

A57791, Billing and Coding: Spinal Cord Stimulators for Chronic Pain

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

A56034, Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy

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

A53065, Billing and Coding: Outpatient Physical Therapy

AETNA-CPB-0016, Back Pain - Invasive Procedures

CIGNA-0509, Intraoperative Monitoring

`M53.81`, Other specified dorsopathies, occipito-atlanto-axial region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M53.81, Other specified dorsopathies, occipito-atlanto-axial region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M53.81`, Other specified dorsopathies, occipito-atlanto-axial region