Does M76.899 require prior authorization?

No, M76.899 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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`M76.899`, Other specified enthesopathies of unspecified 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.
Injection of trigger points is covered only when services meet the reasonable and necessary requirements of Local Coverage Determination L33912.
No specific clinical indications are provided in this billing and coding article; coverage criteria for amniotic and placental-derived product injections/applications for musculoskeletal non-wound indications are described in Local Coverage Determination L39116.
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.

12 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

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-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

A59374, 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

A57114, Billing and Coding: Injection of Trigger Points

`M76.899`, Other specified enthesopathies of unspecified lower limb, excluding foot

Prior Authorization

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

M76.899, Other specified enthesopathies of unspecified lower limb, excluding foot

Prior Authorization

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

`M76.899`, Other specified enthesopathies of unspecified lower limb, excluding foot