Does M65.811 require prior authorization?

No, M65.811 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`M65.811`, Other synovitis and tenosynovitis, right shoulder

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

For multiple injection sites, the record must document the reason for injecting each site and substantiate that all injections were reasonable and necessary.
The medical record must document medical necessity including relevant history, physical exam, and results of pertinent diagnostic tests or procedures supporting the indication for the injection.
The procedure note must be legible and include techniques used, site(s) of injection, drugs with doses/volumes/concentrations, and pre- and post-procedural pain assessments.

Key Coverage Criteria

Injection into tendon sheaths, ligaments, ganglion cysts, carpal tunnel, or tarsal tunnel is covered when medically necessary to diagnose or treat local pain and the medical record documents the clinical reason for the injection at each site.
Diagnostic injections to identify a painful structure are covered when performed no sooner than one week (preferably two) apart and limited to no more than two injections in the diagnostic phase.
Therapeutic injections are covered when a patient had diagnostic injections demonstrating initial pain relief of ≥75–100% with return of function and maintains ≥50% pain relief and functional improvement for at least six weeks.
Attended/manual electrical stimulation (CPT 97032) is covered when the qualified professional provides direct 1-on-1 patient contact to apply/manualy adjust stimulation (e.g., direct motor point stimulation, FES/NMES when combined with therapeutic exercise/neuromuscular reeducation/functional activities).
Non-implantable pelvic floor electrical stimulation delivered via vaginal or anal probes (reportable as CPT 97032) is covered for stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
Unattended/supervised electrical stimulation provided as part of a therapy plan of care (HCPCS G0283) is covered for non-wound indications (e.g., TENS, IFC, cyclical muscle stimulation) when used to control pain and/or swelling and when objective/subjective improvement is documented.

17 Active Policies

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

NGS-J6-L33622, Pain Management - Injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels

NGS-J6-L40268, Pain Management - Injection of tendon sheaths, ligaments, bursa, and ganglion cysts

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A52863, Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels

NGS-J6-L33619, Nonvascular Extremity Ultrasound

A56787, Billing and Coding: Nonvascular Extremity Ultrasound

A59764, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NGS-JK-L33619, Nonvascular Extremity Ultrasound

NGS-JK-L33622, Pain Management - Injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels

NGS-JK-L40268, Pain Management - Injection of tendon sheaths, ligaments, bursa, and ganglion cysts

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A57079, Billing and Coding: Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma

A56619, Billing and Coding: Nerve Conduction Studies and Electromyography

A53065, Billing and Coding: Outpatient Physical Therapy

`M65.811`, Other synovitis and tenosynovitis, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

M65.811, Other synovitis and tenosynovitis, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

`M65.811`, Other synovitis and tenosynovitis, right shoulder