Does M54.51 require prior authorization?

No, M54.51 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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`M54.51`, Vertebrogenic low back pain

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 medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing care to the patient.
Documentation of medical necessity for testing must be maintained in the patient's medical record and must conform to the documentation requirements in LCD L36393.
Every page of the medical record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).
The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.

Key Coverage Criteria

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.
Duplex scanning is covered only when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33674.
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.
When a referring/ordering physician is required by the service or LCD, the test is covered if the ordering/referring physician is documented and the order meets the Local Coverage Determination criteria.
Urine drug testing performed as a diagnostic test or for clinical monitoring when there is a documented medical indication and a valid ICD-10-CM diagnosis code that best describes the patient's condition.
Trigger point injections (TPIs) reported with CPT 20552 (1–2 muscles) or CPT 20553 (3+ muscles) are covered when determined medically reasonable and necessary per the applicable Local Coverage Determination (LCD).

20 Active Policies

CGS-J15-L36029, Urine Drug Testing

J15

CGS-J18-L36029, Urine Drug Testing

J18

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

A59553, Billing and Coding: Trigger Point Injections

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M54.51, Vertebrogenic low back pain