Does M85.851 require prior authorization?

No, M85.851 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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`M85.851`, Other specified disorders of bone density and structure, right thigh

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.

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.
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.

20 Active Policies

CGS-J15-L33996, Vitamin D Assay Testing

J15

CGS-J15-L36460, Bone Mass Measurement

J15

CGS-J18-L33996, Vitamin D Assay Testing

J18

CGS-J18-L36460, Bone Mass Measurement

J18

WPS-J5-L34658, Vitamin D Assay Testing

WPS-J5-L34648, Bisphosphonate Drug Therapy

A56907, Billing and Coding: Bisphosphonate Drug Therapy

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

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

NGS-J6-L37535, Vitamin D Assay Testing

A52421, Billing and Coding: Ibandronate Sodium

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

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

FIRST_COAST-L34021, Sedimentation Rate, Erythrocyte

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

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

`M85.851`, Other specified disorders of bone density and structure, right thigh

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M85.851, Other specified disorders of bone density and structure, right thigh

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M85.851`, Other specified disorders of bone density and structure, right thigh