Does M54.00 require prior authorization?

No, M54.00 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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`M54.00`, Panniculitis affecting regions of neck and back, site unspecified

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 clinical record must document the elements leading to the diagnosis and the conservative therapies tried before electing SCS.
Documentation must be available on request of patient selection criteria, radiologic imaging demonstrating proper lead placement, and medical necessity of trials, particularly for providers under post-payment review.
Appropriate medical documentation to support a repeat trial must be submitted on appeal when extenuating circumstances led to trial failure.

Billing, coding, and documentation requirements (e.g., required medical record elements, coding guidance, prior authorization if applicable) are specified in LCD L39139 and accompanying billing guidance; review LCD L39139 for the exact documentation required for claims.

Key Coverage Criteria

Spinal cord stimulation (SCS) is covered for chronic pain when the clinical record documents the diagnosis and prior conservative therapies tried before the decision to use SCS.
Temporary SCS trials (CPT 63650) are covered when performed in an office, ambulatory surgical center (ASC), outpatient hospital, or hospital with appropriate clinical documentation.
One permanent SCS implant (CPT 63655) is covered per patient when performed in an ASC, outpatient hospital, or hospital and supported by medical necessity documentation.
No specific clinical indications are provided in this billing and coding article; coverage criteria for amniotic and placental-derived product injections/applications for musculoskeletal non-wound indications are described in Local Coverage Determination L39116.
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.
Coverage applies when the amniotic or placental-derived product injection/application meets the reasonable and necessary requirements of Local Coverage Determination L39877.

13 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

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

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

AETNA-CPB-0232, Back Pain - Noninvasive Treatments

AETNA-CPB-0628, Spinal Ultrasound

ANTHEM-RAD.00034, Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)

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

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

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

ANTHEM-CG-MED-97, Biofeedback and Neurofeedback

AETNA-CPB-0010, Continuous Passive Motion (CPM) Machines

AETNA-CPB-0016, Back Pain - Invasive Procedures

`M54.00`, Panniculitis affecting regions of neck and back, site unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

M54.00, Panniculitis affecting regions of neck and back, site unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

13 Active Policies

Related Codes

Have a follow-up question?

`M54.00`, Panniculitis affecting regions of neck and back, site unspecified