Does M76.891 require prior authorization?

No, M76.891 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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`M76.891`, Other specified enthesopathies of right lower limb, excluding foot

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.
Occupational therapy is covered for patients with migraine (G43.xx) who require training to reduce pain during basic and instrumental activities of daily living, typically completed in 3–4 sessions.
Electrical stimulation (attended CPT 97032 or unattended HCPCS G0283) may be covered as part of a therapy plan of care to improve function when the nerve supply to the muscle is intact and atrophy is due to non-neurological disuse (e.g., post-casting, splinting, soft-tissue scarring).
Wheelchair management training (CPT 97542) is covered for patient and/or caregiver training in transfers and propulsion when documentation ties the training to attainable functional goals.

15 Active Policies

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

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

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

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

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

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

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

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

A53065, Billing and Coding: Outpatient Physical Therapy

A53064, Billing and Coding: Outpatient Occupational Therapy

A53057, Billing and Coding: Home Health Occupational Therapy

`M76.891`, Other specified enthesopathies of right lower limb, excluding foot

Prior Authorization

Documentation Required

Key Coverage Criteria

15 Active Policies

Related Codes

Have a follow-up question?

M76.891, Other specified enthesopathies of right lower limb, excluding foot

Prior Authorization

Documentation Required

Key Coverage Criteria

15 Active Policies

Related Codes

Have a follow-up question?

`M76.891`, Other specified enthesopathies of right lower limb, excluding foot