Does M54.59 require prior authorization?

No, M54.59 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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`M54.59`, Other 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

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.
The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.

Key Coverage Criteria

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.
Duplex scanning is covered only when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33674.
Trigger point injections are covered when they meet the reasonable and necessary clinical criteria specified in Local Coverage Determination L35010.
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.

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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M54.59, Other low back pain