Does M53.87 require prior authorization?

No, M53.87 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`M53.87`, Other specified dorsopathies, lumbosacral 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 supported by documentation required by LCD L34576 (medical records demonstrating eligibility, medical necessity, and any prior authorization if applicable).
Follow payer-specific coding, modifiers, and claim form requirements for laparoscopic sleeve gastrectomy as outlined in this billing/coding guidance and the LCD.
A legible medical record must document the condition, clinical findings, relevant prior treatment, and clearly justify the necessity and reasonableness of the lumbar MRI.

Radiologists and ordering physicians must include sufficient clinical information in the MRI report to justify necessity; the MRI report or clinical record must document clinical findings and relevant prior treatment.

Key Coverage Criteria

Billing and coding guidance applies to laparoscopic sleeve gastrectomy (sleeve gastrectomy) performed for severe obesity and is intended to complement LCD L34576.
Use this policy's billing/coding rules when submitting claims for laparoscopic sleeve gastrectomy; follow the clinical indication criteria in LCD L34576 for medical necessity determinations.
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.
Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.

20 Active Policies

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

J15

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

J15

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

J18

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

J18

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

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

A59434, 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

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

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

A58893, 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

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

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

A56852, Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity

A57206, Billing and Coding: Lumbar MRI

A57311, Billing and Coding: Physical Therapy - Home Health

`M53.87`, Other specified dorsopathies, lumbosacral region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M53.87, Other specified dorsopathies, lumbosacral region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M53.87`, Other specified dorsopathies, lumbosacral region