Does M86.611 require prior authorization?

No, M86.611 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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`M86.611`, Other chronic osteomyelitis, 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

The article provides billing and coding guidance and references LCD L39116; required documentation (e.g., medical records, prior authorization, specific forms) is not specified here and must be obtained from LCD L39116.
Billing, coding, and documentation requirements (e.g., required medical record elements, coding guidance, prior authorization if applicable) are specified in LCD L39139 and accompanying billing guidance; review LCD L39139 for the exact documentation required for claims.
The medical record must include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.

Key Coverage Criteria

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.
PET scan is covered to evaluate fever of unknown origin when there is a documented fever curve with temperatures, at least 21 days since fever onset, and documented fevers within the two weeks prior to the PET study.
Coverage applies when the amniotic or placental-derived product injection/application meets the reasonable and necessary requirements of Local Coverage Determination L39877.
Amniotic and placental-derived product injections/applications are covered only when they meet the reasonable and necessary clinical requirements specified in LCD L39879 (Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound).
PET is reasonable for Fever of Unknown Origin (FUO) in patients aged >=18 when fever >38.3 C (101 F) is present for >=21 days (fever on >=2 occasions with repeating episodes for >=2 weeks), the patient is not immunocompromised, history/physical/labs and standard imaging are non-diagnostic, and there are no conditions limiting PET interpretation.

9 Active Policies

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

J15

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

J18

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

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

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

A59374, 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

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

`M86.611`, Other chronic osteomyelitis, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

9 Active Policies

Related Codes

Have a follow-up question?

M86.611, Other chronic osteomyelitis, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

9 Active Policies

Related Codes

Have a follow-up question?

`M86.611`, Other chronic osteomyelitis, right shoulder