Does M79.603 require prior authorization?

No, M79.603 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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`M79.603`, Pain in arm, unspecified

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

Claims and coding must follow the Local Coverage Determination L37642 that this article complements; medical record documentation should support the billed service in accordance with LCD L37642.
For debridement of mycotic nails, the medical record must describe each affected nail (size including thickness, color) and the local symptomatology attributable to each nail for that service encounter.
The patient's medical record must include assessment related to the complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report for the service.
For services requiring a referring/ordering physician, the referring/ordering physician's name and NPI must be reported on the claim; for Part B claims, the attending physician name and NPI and the date last seen (MM/DD/YYYY) must be reported for ICD-10 codes under the active care requirement.

Key Coverage Criteria

Routine foot care and debridement of nails are payable under Medicare Part B when performed in approved places of service (POS 11,12,13,14,19,20[11720/11721 only],21,22,24,31,32,33,49,51,52,53,54,55,56,61,62,65,71,99).
Debridement of mycotic (onychomycosis/dermatophytosis) nails is covered only when the claim lists a primary diagnosis of dermatophytosis of the nail plus either a secondary systemic condition or an ICD-10-CM code from the LCD 'ICD-10-CM Codes that Support Medical Necessity' indicating secondary infection or pain.
Procedures to treat onychogryphosis or onychauxis are covered when the primary diagnosis is onychogryphosis or onychauxis and a secondary diagnosis from the LCD indicating secondary infection or pain is also reported.
Removal of benign hyperkeratotic lesions performed by cutting/parring is reported with CPT 11055, 11056, or 11057 and is the appropriate code set for hyperkeratotic plaques of the foot.
Removal of epidermal and dermal lesions by shaving is reported with CPT 11300–11313 when full-thickness excision is not performed and when anesthesia and hemostasis are provided.
CPT 64450 is appropriate when a qualified health care professional performs a direct injection (nerve block) of an anesthetic agent and/or steroid into a peripheral nerve for treatment of peripheral neuropathy.

13 Active Policies

CGS-J15-L34246, Routine Foot Care and Debridement of Nails

J15

CGS-J18-L34246, Routine Foot Care and Debridement of Nails

J18

A57589, Billing and Coding: Nerve Blocks for Peripheral Neuropathy

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

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M79.603, Pain in arm, unspecified