Does M84.451S require prior authorization?

No, M84.451S 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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`M84.451S`, Pathological fracture, right femur, 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

For CPT 97032, document the type of electrical stimulation (including 'manual'/'attended'), area(s) treated, and if used for muscle weakness provide objective strength ratings and functional deficits; if used for pain provide pain rating, pain location, and effect on function.
For HCPCS G0283, document the type of electrical stimulation (e.g., TENS, IFC), area(s) treated, and objective/subjective measures showing impact on pain intensity/location/functional impact and/or swelling.
For non-implantable pelvic floor stimulation, document cognitive intactness, patient motivation, and a failed documented trial of PME training (defined as no clinically significant improvement after 4 weeks of an ordered PME plan).

Key Coverage Criteria

Attended/manual electrical stimulation (CPT 97032) is covered when the qualified professional provides direct 1-on-1 patient contact to apply/manualy adjust stimulation (e.g., direct motor point stimulation, FES/NMES when combined with therapeutic exercise/neuromuscular reeducation/functional activities).
Non-implantable pelvic floor electrical stimulation delivered via vaginal or anal probes (reportable as CPT 97032) is covered for stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
Unattended/supervised electrical stimulation provided as part of a therapy plan of care (HCPCS G0283) is covered for non-wound indications (e.g., TENS, IFC, cyclical muscle stimulation) when used to control pain and/or swelling and when objective/subjective improvement is documented.
Electromagnetic therapy (HCPCS G0329) is covered for chronic stage III and IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.
Unattended electrical stimulation for wound management (HCPCS G0281) is covered for chronic stage III and IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers that have not shown measurable healing after 30 days of conventional care.
Coverage for lower extremity major joint replacement (hip and knee) is subject to the reasonable and necessary requirements of Local Coverage Determination L36007; services meeting LCD L36007 criteria are covered.

20 Active Policies

CGS-J15-L40232, Total Joint Arthroplasty

J15

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

A59811, Billing and Coding: Total Joint Arthroplasty

WPS-J5-L39911, Total Joint Arthroplasty

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

WPS-J8-L39911, Total Joint Arthroplasty

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

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

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

NOVITAS-JH-L36007, Lower Extremity Major Joint Replacement (Hip and Knee)

A56796, Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee)

NOVITAS-JL-L36007, Lower Extremity Major Joint Replacement (Hip and Knee)

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

A57206, Billing and Coding: Lumbar MRI

A57311, Billing and Coding: Physical Therapy - Home Health

A57683, Billing and Coding: Total Hip Arthroplasty

A57685, Billing and Coding: Total Knee Arthroplasty

A53065, Billing and Coding: Outpatient Physical Therapy

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

`M84.451S`, Pathological fracture, right femur, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M84.451S, Pathological fracture, right femur, sequela

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M84.451S`, Pathological fracture, right femur, sequela