Does M80.811K require prior authorization?

No, M80.811K 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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`M80.811K`, Other osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with nonunion

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

WPS-J5-L34658, Vitamin D Assay Testing

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

A57484, Billing and Coding: Vitamin D Assay Testing

A57736, Billing and Coding: Vitamin D Assay Testing

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

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

A52421, Billing and Coding: Ibandronate Sodium

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

WPS-J8-L34658, Vitamin D Assay Testing

A56841, Billing and Coding: Vitamin D; 25 hydroxy, includes fraction(s), if performed

A59764, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

FIRST_COAST-L33771, Vitamin D; 25 hydroxy, includes fraction(s), if performed

NOVITAS-JH-L34914, Assays for Vitamins and Metabolic Function

NGS-JK-L37535, Vitamin D Assay Testing

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

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A56416, Billing and Coding: Assays for Vitamins and Metabolic Function

NOVITAS-JL-L34914, Assays for Vitamins and Metabolic Function

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

`M80.811K`, Other osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with nonunion

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M80.811K, Other osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with nonunion

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M80.811K`, Other osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with nonunion