Does M75.42 require prior authorization?

No, M75.42 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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`M75.42`, Impingement syndrome of left 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

The medical record must document relevant medical history, physical examination, pertinent diagnostic test/procedure results, and history of pharmacologic therapy supporting medical necessity.
Documentation for subsequent courses must clearly establish reduction in patient symptomatology and medication usage and must be available upon request.
Append appropriate site modifier (RT or LT) to CPT 20610/20611 for unilateral services and modifier 50 to indicate bilateral services.
Use the EJ modifier on drug codes to indicate subsequent injections of a series; do not use EJ for the first injection of each series.

Key Coverage Criteria

Intra-articular hyaluronan injections are covered for pain associated with osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics.
Intra-articular hyaluronan injections may be used as a therapeutic option for osteoarthritis of the shoulder.
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.

20 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

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M75.42, Impingement syndrome of left shoulder