Does M54.10 require prior authorization?

No, M54.10 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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`M54.10`, Radiculopathy, 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

Claims and documentation requirements for CPNB are governed by and must follow the Local Coverage Determination L37641 referenced by this guideline.
Medical necessity for each test must be documented in the patient's medical record as required by LCD L35006.
All documentation must be maintained in the patient's medical record and made available to the contractor upon request; every page must be legible and include patient identification and dates of service.
Documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.

Key Coverage Criteria

No specific coverage indications are stated in this billing/coding guideline; refer to Local Coverage Determination L37641 for covered indications for continuous peripheral nerve blocks (CPNB).
Urine drug testing (UDT) and drugs-of-abuse testing are covered when reasonable and necessary per LCD L35006 and ordered on an individual patient basis by the treating clinician with medical-record documentation of medical necessity.
Patients with a documented diagnosis consistent with substance use disorder (SUD) may qualify for an exception to the standard presumptive UDT annual limits.
Controlled substance monitoring and drugs-of-abuse testing are covered when individually ordered by the treating clinician and meet the reasonable and necessary requirements specified in LCD L36393.
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.

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

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

A57452, Billing and Coding: Peripheral Nerve Blocks

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M54.10, Radiculopathy, site unspecified