Does M86.452 require prior authorization?

No, M86.452 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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`M86.452`, Chronic osteomyelitis with draining sinus, left femur

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

The medical record must clearly document that the coverage indications, limitations, and medical necessity criteria in L37228 Wound Care have been met for any billed wound care item or service.
Documentation must support the specific CPT/HCPCS code(s) billed, including procedure details, depth and surface area for debridement codes, and rationale for the service.
When hydrotherapy (whirlpool) is billed with CPT 97597 or 97598, the record must state why hydrotherapy was necessary to remove devitalized/necrotic tissue and that a therapist's skill was required to perform the service.

Key Coverage Criteria

Traditional negative pressure wound therapy (NPWT) devices, units, and supplies are covered under the Durable Medical Equipment (DME) benefit when they meet DME LCD coverage criteria and medical necessity.
CPT codes 97597, 97598, and wound debridement codes 11042-11047 may be covered when the medical record documents medical necessity consistent with L37228 Wound Care criteria and Medicare reasonable-and-necessary requirements.
A valid ICD-10-CM diagnosis code that best describes the patient’s condition for which the debridement service was performed must be reported on the claim.
When a service requires a referring or ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.

16 Active Policies

CGS-J15-L34032, Debridement Services

J15

CGS-J15-L39521, Positron Emission Tomography (PET) Scan for Inflammation and Infection

J15

CGS-J18-L34032, Debridement Services

J18

CGS-J18-L39521, Positron Emission Tomography (PET) Scan for Inflammation and Infection

J18

WPS-J5-L37228, Wound Care

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

A55909, Billing and Coding: Wound Care

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

WPS-J8-L37228, Wound Care

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

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

A59318, Billing and Coding: Positron Emission Tomography (PET) Scan for Inflammation and Infection

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

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

A57206, Billing and Coding: Lumbar MRI

A56459, Billing and Coding: Debridement Services

`M86.452`, Chronic osteomyelitis with draining sinus, left femur

Prior Authorization

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

M86.452, Chronic osteomyelitis with draining sinus, left femur

Prior Authorization

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

`M86.452`, Chronic osteomyelitis with draining sinus, left femur