Does M80.8B1S require prior authorization?

No, M80.8B1S 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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`M80.8B1S`, Other osteoporosis with current pathological fracture, right pelvis, sequela

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 and made available to the contractor upon request, with every page legible and including patient identification (complete name, dates of service).
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.

Key Coverage Criteria

25-hydroxy vitamin D testing (including fractions, if performed) is covered when deemed reasonable and necessary per Local Coverage Determination L33771.
Intravenous bisphosphonate administration is covered for treatment of osteoporosis when medical record documents need for IV route, including description of treatment failure of oral or self‑administered osteoporosis drugs.
Bisphosphonate therapy is covered for heterotopic ossification when the medical record documents clinical need for treatment and justifies IV administration.
Bisphosphonate therapy is covered for bone metastasis (C79.51 or C79.52) provided the patient's record also contains a diagnosis of the primary malignant neoplasm.
In breast cancer patients receiving adjuvant selective estrogen receptor modulators or aromatase inhibitor therapy, bisphosphonates are covered when billed with an appropriate breast cancer diagnosis code and a bone loss diagnosis code documenting treatment indication.
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).

20 Active Policies

CGS-J15-L40232, Total Joint Arthroplasty

J15

CGS-J15-L36460, Bone Mass Measurement

J15

CGS-J18-L36460, Bone Mass Measurement

J18

CGS-J18-L40232, Total Joint Arthroplasty

J18

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

WPS-J5-L34658, Vitamin D Assay Testing

A57484, Billing and Coding: Vitamin D Assay Testing

A57604, Billing and Coding: Intraoperative Neurophysiological Testing

WPS-J5-L39911, Total Joint Arthroplasty

A59811, Billing and Coding: Total Joint Arthroplasty

A56907, Billing and Coding: Bisphosphonate Drug Therapy

WPS-J5-L34623, Intraoperative Neurophysiological Testing

WPS-J5-L34648, Bisphosphonate Drug Therapy

WPS-J8-L39911, Total Joint Arthroplasty

WPS-J8-L34658, Vitamin D Assay Testing

WPS-J8-L34648, Bisphosphonate Drug Therapy

WPS-J8-L34623, Intraoperative Neurophysiological Testing

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

FIRST_COAST-L33618, Major Joint Replacement (Hip and Knee)

A57765, Billing and Coding: Major Joint Replacement (Hip and Knee)

`M80.8B1S`, Other osteoporosis with current pathological fracture, right pelvis, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M80.8B1S, Other osteoporosis with current pathological fracture, right pelvis, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M80.8B1S`, Other osteoporosis with current pathological fracture, right pelvis, sequela