Does M96.0 require prior authorization?

No, M96.0 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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`M96.0`, Pseudarthrosis after fusion or arthrodesis

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

All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
Every page of the medical record must be legible and include appropriate patient identification information such as complete name and dates of service.
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the patient’s care.
The submitted medical record must support the use of the selected ICD-10-CM code(s).

Key Coverage Criteria

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.
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.
Cervical fusion and related cervical spine fusion procedures are the only procedures covered under this policy; other joint or non-cervical spinal procedures (e.g., facet, sacroiliitis, epidural) are not covered by this policy.
Coverage for a cervical fusion procedure is allowed only when the service meets the reasonable and necessary clinical criteria and frequency limitations specified in the applicable draft Local Coverage Determination (LCD) Cervical Fusion.
Cervical fusion procedures are covered when they meet the reasonable and necessary clinical criteria and frequency limits specified in Local Coverage Determination (LCD) L39788.
Cervical fusion and related cervical-spine fusion procedures are within the scope of this billing/coding guidance and are covered when they meet the reasonable and necessary requirements in LCD L39793.

20 Active Policies

CGS-J15-L39741, Cervical Fusion

J15

CGS-J18-L39741, Cervical Fusion

J18

WPS-J5-L39788, Cervical Fusion

A59664, Billing and Coding: Cervical Fusion

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

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M96.0, Pseudarthrosis after fusion or arthrodesis