Does M88.861 require prior authorization?

No, M88.861 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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`M88.861`, Osteitis deformans of right lower leg

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.
CPT 97032 (attended/manual electrical stimulation) is covered when delivered with direct 1-on-1 contact by qualified personnel (examples: direct motor point stimulation; FES/NMES when performed with therapeutic exercise, neuromuscular reeducation, or functional activities).
CPT 97032 may be billed for the application, instruction, and adjustment of a TENS unit or other probe-based stimulation (including determining trigger points) when provided as an attended/manual modality.

20 Active Policies

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

A56907, Billing and Coding: Bisphosphonate Drug Therapy

WPS-J5-L34648, Bisphosphonate Drug Therapy

WPS-J5-L34658, Vitamin D Assay Testing

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

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-L34648, Bisphosphonate Drug Therapy

WPS-J8-L34658, Vitamin D Assay Testing

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

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

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

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

A56796, Billing and Coding: 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

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

A56777, Billing and Coding: Total Joint Arthroplasty

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

A53064, Billing and Coding: Outpatient Occupational Therapy

`M88.861`, Osteitis deformans of right lower leg

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M88.861, Osteitis deformans of right lower leg

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M88.861`, Osteitis deformans of right lower leg