Does M54.9 require prior authorization?

No, M54.9 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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`M54.9`, Dorsalgia, unspecified

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.
NC-stat testing (CPT 95905) is allowed when the beneficiary has a high pre-test or prior probability of Carpal Tunnel Syndrome (CTS), limited to one service per arm.
Use CPT 95870 for sampling muscles other than the paraspinals associated with the extremities that have been tested.
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.

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

NGS-J6-L35098, Nerve Conduction Studies and Electromyography

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M54.9, Dorsalgia, unspecified