Does M85.811 require prior authorization?

No, M85.811 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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`M85.811`, Other specified disorders of bone density and structure, right shoulder

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.
Bone mass measurement tests are covered when ordered by the treating physician or a qualified non-physician practitioner authorized by state law.

20 Active Policies

CGS-J15-L33996, Vitamin D Assay Testing

J15

CGS-J15-L36460, Bone Mass Measurement

J15

CGS-J18-L36460, Bone Mass Measurement

J18

CGS-J18-L33996, Vitamin D Assay Testing

J18

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

WPS-J5-L34648, Bisphosphonate Drug Therapy

A56907, Billing and Coding: Bisphosphonate Drug Therapy

A57484, 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

WPS-J8-L34658, Vitamin D Assay Testing

WPS-J8-L34648, Bisphosphonate Drug Therapy

A57657, Billing and Coding: Sedimentation Rate, Erythrocyte

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

FIRST_COAST-L34021, Sedimentation Rate, Erythrocyte

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

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

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

A57132, Billing and Coding: Bone Mass Measurement

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

`M85.811`, Other specified disorders of bone density and structure, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M85.811, Other specified disorders of bone density and structure, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M85.811`, Other specified disorders of bone density and structure, right shoulder