Does M79.5 require prior authorization?

No, M79.5 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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`M79.5`, Residual foreign body in soft tissue

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 clearly document that the coverage indications, limitations, and medical necessity criteria in L37228 Wound Care have been met for any billed wound care item or service.
Documentation must support the specific CPT/HCPCS code(s) billed, including procedure details, depth and surface area for debridement codes, and rationale for the service.
When hydrotherapy (whirlpool) is billed with CPT 97597 or 97598, the record must state why hydrotherapy was necessary to remove devitalized/necrotic tissue and that a therapist's skill was required to perform the service.
If CPT 97597 or 97598 is billed by a therapist while the patient is under a Home Health benefit, coverage depends on inclusion in the Home Health plan of care; if billed by a physician or non-physician practitioner it is paid under Part B even if the beneficiary has an active Home Health plan.

Key Coverage Criteria

Traditional negative pressure wound therapy (NPWT) devices, units, and supplies are covered under the Durable Medical Equipment (DME) benefit when they meet DME LCD coverage criteria and medical necessity.
CPT codes 97597, 97598, and wound debridement codes 11042-11047 may be covered when the medical record documents medical necessity consistent with L37228 Wound Care criteria and Medicare reasonable-and-necessary requirements.
Nonvascular extremity ultrasound is covered when medical necessity is documented in the patient's record, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Diagnostic nonvascular extremity ultrasound is covered when the claim includes an ICD-10-CM diagnosis code that best describes the patient's condition and the test result or the symptoms prompting the test are documented.
Trigger point injections (CPT 20552 or 20553) are covered when medically necessary to treat documented myofascial trigger points causing pain, with procedural documentation supporting medical necessity.
CPT 20552 may be reported for trigger point injections involving 1 or 2 muscles; CPT 20553 may be reported for injections involving 3 or more muscles.

17 Active Policies

A55909, Billing and Coding: Wound Care

A59553, Billing and Coding: Trigger Point Injections

WPS-J5-L37228, Wound Care

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

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M79.5, Residual foreign body in soft tissue