Does M87.251 require prior authorization?

No, M87.251 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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`M87.251`, Osteonecrosis due to previous trauma, right 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

Documentation for CPT 97010, 97018, 97022, and 97026 must reflect medical necessity and be made available to the MAC upon request.
When billing a Z-code as the diagnosis, documentation must include the orthotic/prosthetic device name, date patient received the device, and date training/teaching began.
Documentation for CPT 97542 wheelchair propulsion training must relate the training to expected, attainable functional goals for the patient and/or caregiver.

Key Coverage Criteria

CPT 97110 may be billed when treating impairments of exercise tolerance due to cardiopulmonary impairments.
CPT 97542 (wheelchair management training) may be billed for wheelchair propulsion training when the training is tied to expected functional goals attainable by the patient or caregiver.
Home health physical therapy services are appropriate when based on impairments of body structure/function and demonstrable functional limitations consistent with the related LCD.
Coverage for lower extremity major joint replacement (hip and knee) is subject to the reasonable and necessary requirements of Local Coverage Determination L36007; services meeting LCD L36007 criteria are covered.
Simultaneous bilateral hip or knee replacement during the same encounter is covered when medical necessity for bilateral procedure is documented; bilateral procedures are subject to bilateral pricing.
Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is covered for advanced joint disease when arthritis of the hip or knee is supported by X-ray or MRI demonstrating subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, or avascular necrosis.

20 Active Policies

CGS-J15-L40232, Total Joint Arthroplasty

J15

CGS-J18-L40232, Total Joint Arthroplasty

J18

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

WPS-J5-L39911, Total Joint Arthroplasty

A59811, Billing and Coding: Total Joint Arthroplasty

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

WPS-J8-L39911, Total Joint Arthroplasty

FIRST_COAST-L33618, Major Joint Replacement (Hip and Knee)

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

A57765, Billing and Coding: Major Joint Replacement (Hip and Knee)

NOVITAS-JH-L36007, Lower Extremity Major Joint Replacement (Hip and Knee)

NOVITAS-JL-L36007, Lower Extremity Major Joint Replacement (Hip and Knee)

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

A56796, Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee)

A60250, Billing and Coding: Total Joint Arthroplasty

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

AETNA-CPB-0364, Allograft Transplants of the Extremities

AETNA-CPB-0599, Autologous Skeletal Myoblast/Mononuclear Bone Marrow Cell Transplantation

AETNA-CPB-0753, Core Decompression for Avascular Necrosis

A53058, Billing and Coding: Home Health Physical Therapy

`M87.251`, Osteonecrosis due to previous trauma, right femur

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M87.251, Osteonecrosis due to previous trauma, right femur

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M87.251`, Osteonecrosis due to previous trauma, right femur