Does M54.89 require prior authorization?

No, M54.89 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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`M54.89`, Other dorsalgia

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.
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).
EMG and/or nerve conduction studies are indicated for evaluation of suspected polyneuropathy or mononeuropathy multiplex.
EMG is indicated for evaluation of suspected myopathy.

20 Active Policies

CGS-J15-L39506, Cosmetic and Reconstructive Surgery

J15

CGS-J15-L35897, Nerve Conduction Studies and Electromyography

J15

CGS-J18-L39506, Cosmetic and Reconstructive Surgery

J18

CGS-J18-L35897, Nerve Conduction Studies and Electromyography

J18

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M54.89, Other dorsalgia