Does M80.052A require prior authorization?

No, M80.052A 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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`M80.052A`, Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture

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 management of hypercalcemia of malignancy document ICD-10-CM code E83.52, the related malignancy, and the rationale for denosumab use.
Medical record must contain documentation that fully supports the medical necessity for administration of the specific denosumab formulation used.
For postmenopausal osteoporosis include menopausal status (female), age and sex, documentation supporting the osteoporosis diagnosis, prior osteoporosis treatments and outcomes/adverse reactions, prior fracture history (type, cause, time), and fracture risk factors/preventive measures.

Key Coverage Criteria

Denosumab is covered for postmenopausal osteoporosis in patients at high risk for fracture when medical record documents menopausal status, diagnosis of osteoporosis, prior osteoporosis treatments and outcomes, fracture history, and fracture risk factors.
Denosumab is covered for cancer treatment–induced bone loss (CTIBL) in patients with breast cancer receiving adjuvant aromatase inhibitors (AI) or in patients with nonmetastatic prostate cancer receiving androgen deprivation therapy (ADT) when documentation supports the cancer diagnosis and therapy.
Denosumab is covered for treatment of bone metastasis from a solid tumor when the claim lists bone metastasis (ICD-10-CM C79.51) as the primary diagnosis and the original cancer or history of cancer is included as the secondary diagnosis.
Denosumab is covered for management of hypercalcemia of malignancy when ICD-10-CM code E83.52 and the related malignancy and clinical rationale are documented.
Denosumab (Xgeva®) is covered for treatment of skeletal-related events in patients with multiple myeloma per FDA approval effective 01/04/2018 when clinical rationale is documented.
Coverage requires that the patient be adequately supplemented with calcium (1000 mg daily) and vitamin D (at least 400 IU daily) and that hypocalcemia be corrected prior to initiation of denosumab.

20 Active Policies

CGS-J15-L40232, Total Joint Arthroplasty

J15

CGS-J15-L33996, Vitamin D Assay Testing

J15

CGS-J18-L33996, Vitamin D Assay Testing

J18

CGS-J18-L40232, Total Joint Arthroplasty

J18

WPS-J5-L34648, Bisphosphonate Drug Therapy

A56907, Billing and Coding: Bisphosphonate Drug Therapy

A57484, Billing and Coding: Vitamin D Assay Testing

A59811, Billing and Coding: Total Joint Arthroplasty

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

WPS-J5-L39911, Total Joint Arthroplasty

WPS-J5-L34658, Vitamin D Assay Testing

A52421, Billing and Coding: Ibandronate Sodium

A52399, Billing and Coding: Denosumab (Prolia, Xgeva, Jubbonti, Wyost, Ospomyv,Xbryk,Bomyntra, Conexxence, Stoboclo, Osenvelt,Bildyos, Bilprevda)

A57736, Billing and Coding: Vitamin D Assay Testing

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NGS-J6-L37535, Vitamin D Assay Testing

WPS-J8-L34648, Bisphosphonate Drug Therapy

WPS-J8-L39911, Total Joint Arthroplasty

WPS-J8-L34658, Vitamin D Assay Testing

`M80.052A`, Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M80.052A, Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M80.052A`, Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture