Does M86.461 require prior authorization?

No, M86.461 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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`M86.461`, Chronic osteomyelitis with draining sinus, right tibia and fibula

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.
No specific clinical indications are provided in this billing and coding article; coverage criteria for amniotic and placental-derived product injections/applications for musculoskeletal non-wound indications are described in Local Coverage Determination L39116.
Coverage for amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications is determined by Local Coverage Determination L39139; consult LCD L39139 for specific clinical indications and thresholds.

16 Active Policies

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

J15

CGS-J15-L34032, Debridement Services

J15

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

J18

CGS-J18-L34032, Debridement Services

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

A56459, Billing and Coding: Debridement Services

AETNA-CPB-0171, Magnetic Resonance Imaging (MRI) of the Extremities

`M86.461`, Chronic osteomyelitis with draining sinus, right tibia and fibula

Prior Authorization

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

M86.461, Chronic osteomyelitis with draining sinus, right tibia and fibula

Prior Authorization

Documentation Required

Key Coverage Criteria

16 Active Policies

Related Codes

Have a follow-up question?

`M86.461`, Chronic osteomyelitis with draining sinus, right tibia and fibula