Does M66.811 require prior authorization?

No, M66.811 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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`M66.811`, Spontaneous rupture of other tendons, 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.
CPT 97110 may be billed when treating impairments of exercise tolerance due to cardiopulmonary impairments.
CPT 97542 (wheelchair management training) may be billed for wheelchair propulsion training when the training is tied to expected functional goals attainable by the patient or caregiver.
Home health physical therapy services are appropriate when based on impairments of body structure/function and demonstrable functional limitations consistent with the related LCD.

18 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

A56787, Billing and Coding: Nonvascular Extremity Ultrasound

NGS-J6-L33619, Nonvascular Extremity Ultrasound

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

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

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

A53065, Billing and Coding: Outpatient Physical Therapy

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

A53064, Billing and Coding: Outpatient Occupational Therapy

A53058, Billing and Coding: Home Health Physical Therapy

AETNA-CPB-0244, Skin and Soft Tissue Substitutes

`M66.811`, Spontaneous rupture of other tendons, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

18 Active Policies

Related Codes

Have a follow-up question?

M66.811, Spontaneous rupture of other tendons, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

18 Active Policies

Related Codes

Have a follow-up question?

`M66.811`, Spontaneous rupture of other tendons, right shoulder