Does M79.10 require prior authorization?

No, M79.10 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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`M79.10`, Myalgia, unspecified site

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

All documentation must be maintained in the patient medical record, be legible, include patient identification and the identity of the physician or non-physician practitioner responsible for care, and be available to the contractor upon request.
Medical record documentation maintained by the ordering/treating physician must indicate the medical necessity and clinical indication(s) that led to ordering the drug test and support the selected diagnosis and CPT/HCPCS code(s).
All tests must be ordered in writing by the treating provider and the order must specify all drugs/drug classes to be tested; the physician’s order must include the clinical indication/medical necessity.
If the performing provider is different from the ordering/referring physician, the performing provider must maintain hard copy documentation of lab results and copies of the ordering physician’s order for the drug test.

Key Coverage Criteria

Urine, blood, or oral fluid specimens may be used for drug testing, with urine preferred for broad screening of common drugs.
Medicare Part B will pay for drug screening services when all coverage criteria, limitations, and medical necessity requirements of LCD DL34645 are met.
Claims for drug screening services are payable under Medicare Part B only in these places of service: office (11), urgent care (20), independent clinic (49), federally qualified health center — freestanding (50), rural health clinic — freestanding (72), and independent laboratory (81).
Vitamin D assay testing is payable under Medicare Part B when performed in an office (POS 11), independent clinic (POS 49), Federally Qualified Health Center (POS 50), or independent laboratory (POS 81).
Non-physician practitioners (e.g., nurse practitioners, clinical nurse specialists, physician assistants) may certify, order, and establish the plan of care for Vitamin D assay testing as authorized by State law (outpatient settings other than CORFs).
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.

20 Active Policies

CGS-J15-L39656, Trigger Point Injections (TPI)

J15

CGS-J15-L36029, Urine Drug Testing

J15

CGS-J18-L39656, Trigger Point Injections (TPI)

J18

CGS-J18-L36029, Urine Drug Testing

J18

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

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M79.10, Myalgia, unspecified site