Does M53.85 require prior authorization?

No, M53.85 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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`M53.85`, Other specified dorsopathies, thoracolumbar 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

Claims must be submitted in accordance with CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 32 Section 150 (Billing Requirements for Bariatric Surgery for Morbid Obesity), including use of the procedure and diagnosis codes listed there and in this local article.
Coverage for Type II diabetes mellitus complication diagnosis codes is based on the Internet Only Manual (IOM); include documentation and citations required by IOM when billing these diagnoses.
Bariatric surgery claims must reference the applicable national coverage determination (CMS Pub 100-03 Chapter 1 Part 2 Section 100.1) when submitting for payment.

Key Coverage Criteria

Bariatric surgery for treatment of co-morbid conditions related to morbid obesity is payable when billed in accordance with CMS Pub 100-03 Medicare National Coverage Determinations Manual, Chapter 1 Part 2 Section 100.1.
Additional diagnoses listed in this local coverage article for Part A procedure codes and the article's listed CPT codes are covered for bariatric surgery to treat co-morbid conditions related to morbid obesity.
Automated nerve conduction testing using the NC-stat (CPT 95905) is allowed only when there is a high pre-test or prior probability of carpal tunnel syndrome and the claim uses diagnosis code G56.01 or G56.02; allowed one service per arm.
If authorized by state law, physical therapists (PTs) are allowed to perform the technical and professional components of nerve conduction studies represented by CPT codes 95907-95913 consistent with a 7A supervision designation (effective 01/01/2013).
If authorized by state law, the technical component of neuromuscular junction testing CPT 95937 (TC) with supervision designation 7A is allowable for PTs consistent with the 7A description (effective 01/01/2013).
Needle electromyography CPT codes 95860-95872 and 95885-95887 have a 6A designation for the technical portion; PTs who are ABPTS-certified as qualified electrophysiologic clinical specialists and are authorized by state law may perform the technical and professional components according to the 6A description.

20 Active Policies

CGS-J15-L38773, Facet Joint Interventions for Pain Management

J15

CGS-J18-L38773, Facet Joint Interventions for Pain Management

J18

A58477, Billing and Coding: Facet Joint Interventions for Pain Management

WPS-J5-L38841, Facet Joint Interventions for Pain Management

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

A54923, Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity

NGS-J6-L35936, Facet Joint Interventions for Pain Management

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

A57826, Billing and Coding: Facet Joint Interventions for Pain Management

WPS-J8-L38841, Facet Joint Interventions for Pain Management

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

NGS-JK-L35936, Facet Joint Interventions for Pain Management

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

A57206, Billing and Coding: Lumbar MRI

A58350, Billing and Coding: Facet Joint Interventions for Pain Management

A58364, Billing and Coding: Facet Joint Interventions for Pain Management

A58403, Billing and Coding: Facet Joint Interventions for Pain Management

A56695, Billing and Coding: Implantable Infusion Pump

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

A56619, Billing and Coding: Nerve Conduction Studies and Electromyography

`M53.85`, Other specified dorsopathies, thoracolumbar region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

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M53.85, Other specified dorsopathies, thoracolumbar region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M53.85`, Other specified dorsopathies, thoracolumbar region