Does M54.16 require prior authorization?

No, M54.16 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

`M54.16`, Radiculopathy, lumbar 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 medical record, be legible, include patient identification and the identity of the physician or non-physician practitioner responsible for care, and be available to the contractor upon request.
Medical record documentation maintained by the ordering/treating physician must indicate the medical necessity and clinical indication(s) that led to ordering the drug test and support the selected diagnosis and CPT/HCPCS code(s).
All tests must be ordered in writing by the treating provider and the order must specify all drugs/drug classes to be tested; the physician’s order must include the clinical indication/medical necessity.
If the performing provider is different from the ordering/referring physician, the performing provider must maintain hard copy documentation of lab results and copies of the ordering physician’s order for the drug test.

Key Coverage Criteria

Urine, blood, or oral fluid specimens may be used for drug testing, with urine preferred for broad screening of common drugs.
Medicare Part B will pay for drug screening services when all coverage criteria, limitations, and medical necessity requirements of LCD DL34645 are met.
Claims for drug screening services are payable under Medicare Part B only in these places of service: office (11), urgent care (20), independent clinic (49), federally qualified health center — freestanding (50), rural health clinic — freestanding (72), and independent laboratory (81).
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.
Electrodiagnostic testing (EMG and/or nerve conduction studies) is indicated for evaluation of suspected carpal tunnel syndrome.

20 Active Policies

CGS-J15-L36029, Urine Drug Testing

J15

CGS-J15-L35897, Nerve Conduction Studies and Electromyography

J15

CGS-J15-L39015, Epidural Steroid Injections for Pain Management

J15

CGS-J18-L39015, Epidural Steroid Injections for Pain Management

J18

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about M54.16 Sign up free

M54.16, Radiculopathy, lumbar region