Does M54.11 require prior authorization?

No, M54.11 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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`M54.11`, Radiculopathy, 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

All documentation must be maintained in the patient's medical record, legible, include patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
The submitted medical record must support the selected ICD-10-CM code(s), the submitted CPT/HCPCS code must describe the service performed, and the record must clearly document medical necessity, the indication for ordering the test, and a clear diagnostic impression.

Key Coverage Criteria

Nerve conduction studies (NCS) without needle EMG (NEMG) are allowed for individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome when one of the following ICD-10-CM codes is reported: G56.01, G56.02, G56.03, G56.11, G56.12, G56.13, G56.21, G56.22, G56.23, G57.51, G57.52, or G57.53.
NCS without NEMG is allowed for individuals with significant lymphedema in the affected extremity when ICD-10-CM code I89.0 is reported in addition to the primary diagnosis.
NCS without NEMG is allowed for individuals treated with anticoagulants when ICD-10-CM code Z79.01 or Z79.02 is reported in addition to the primary diagnosis.
Electrodiagnostic testing (EMG and/or nerve conduction studies) is indicated for evaluation of suspected carpal tunnel syndrome.
EMG and/or nerve conduction studies are indicated for evaluation of suspected radiculopathy.
EMG and/or nerve conduction studies are indicated for evaluation of suspected mononeuropathy (single-nerve entrapment or injury).

20 Active Policies

CGS-J15-L35897, Nerve Conduction Studies and Electromyography

J15

CGS-J15-L39741, Cervical Fusion

J15

CGS-J18-L39741, Cervical Fusion

J18

CGS-J18-L35897, Nerve Conduction Studies and Electromyography

J18

A59664, Billing and Coding: Cervical Fusion

WPS-J5-L34594, Nerve Conduction Studies and Electromyography

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

WPS-J5-L39788, Cervical Fusion

A57478, Billing and Coding: Nerve Conduction Studies and Electromyography

A57668, Billing and Coding: Nerve Conduction Studies and Electromyography

A59632, Billing and Coding: Cervical Fusion

NGS-J6-L39770, Cervical Fusion

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

NGS-J6-L35098, Nerve Conduction Studies and Electromyography

WPS-J8-L39788, Cervical Fusion

WPS-J8-L34594, Nerve Conduction Studies and Electromyography

A57123, Billing and Coding: Nerve Conduction Studies and Electromyography

FIRST_COAST-L39799, Cervical Fusion

FIRST_COAST-L34859, Nerve Conduction Studies and Electromyography

A59674, Billing and Coding: Cervical Fusion

`M54.11`, Radiculopathy, occipito-atlanto-axial region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M54.11, Radiculopathy, occipito-atlanto-axial region

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M54.11`, Radiculopathy, occipito-atlanto-axial region