Does M54.6 require prior authorization?

No, M54.6 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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`M54.6`, Pain in thoracic spine

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

Documentation supporting the claim must be maintained in the medical record and be available to Medicare upon request.
Each claim must be submitted with ICD-10-CM code(s) that reflect the patient's condition and reasons for the service; claims without ICD-10-CM codes will be returned.
For diagnostic tests related to the service, report the test result if known; if the result is not known, report the signs or symptoms that prompted the test.
The patient's medical record must contain documentation that fully supports the medical necessity of the reduction mammaplasty, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Key Coverage Criteria

Follow the related Local Coverage Determination (LCD) for clinical indications and medical necessity criteria for reduction mammaplasty.
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.
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-L39506, Cosmetic and Reconstructive Surgery

J15

CGS-J15-L36029, Urine Drug Testing

J15

CGS-J15-L35897, Nerve Conduction Studies and Electromyography

J15

CGS-J18-L35897, Nerve Conduction Studies and Electromyography

J18

CGS-J18-L39506

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M54.6, Pain in thoracic spine