Does M81.6 require prior authorization?

No, M81.6 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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`M81.6`, Localized osteoporosis [Lequesne]

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

Medical record documentation must demonstrate that the patient cannot tolerate oral bisphosphonates or that oral bisphosphonates are medically contraindicated (including documentation of severe esophagitis when applicable).
If inability to tolerate oral ibandronate is claimed, include appropriate intolerance/interaction codes (T50.995A-T50.995S, Y63.8, Z91.89, or Z92.89) in the documentation and claims as applicable.
For hypercalcemia of malignancy (E83.52), document the clinical rationale for ibandronate use and the specific related malignancy in the patient record.
For osteoporosis as a transplant complication, include the related transplant complication code plus T50.995A-T50.995S or Z87.19 to justify intravenous therapy.

Key Coverage Criteria

Intravenous ibandronate sodium is reasonable and necessary only for patients for whom bisphosphonate therapy (including oral ibandronate) is medically indicated and who cannot tolerate oral therapy or have a medical contraindication to oral bisphosphonates.
Use for osteoporosis (including senile or other osteoporosis) is covered when oral bisphosphonate therapy is indicated but cannot be used due to intolerance or contraindication.
Ibandronate sodium may be used for management of hypercalcemia of malignancy when the medical record documents the rationale for use and the related malignancy.
Ibandronate sodium may be used for osteoporosis that is a complication of transplant when the claim includes the related complication-of-transplant code and documentation of inability to tolerate oral bisphosphonates.
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.

20 Active Policies

CGS-J15-L36460, Bone Mass Measurement

J15

CGS-J15-L33996, Vitamin D Assay Testing

J15

CGS-J18-L33996, Vitamin D Assay Testing

J18

CGS-J18-L36460, Bone Mass Measurement

J18

A56907, Billing and Coding: Bisphosphonate Drug Therapy

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M81.6, Localized osteoporosis [Lequesne]