Does Q74.9 require prior authorization?

No, Q74.9 does not require prior authorization (high confidence). Covered without prior authorization.

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`Q74.9`, Unspecified congenital malformation of limb(s)

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medicare requires that each radiograph set include multiple views of the fracture site accompanied by a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs.
For non-spinal electrical stimulation (Medicare): nonunion of a long bone fracture must be documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including multiple views of the fracture site, and with a written interpretation by a physician stating there has been no clinically significant evidence of fracture healing between the two sets of radiographs.
For spine fusion electrical stimulation coverage: documentation that the patient meets one of the Medicare-supported indications (failed spinal fusion with minimum of nine months elapsed since last surgery; multilevel spinal fusion [3 or more vertebrae]; or history of previously failed spinal fusion at same site).

Key Coverage Criteria

Medicare allows ultrasonic osteogenesis stimulators only if all of the following criteria are met: nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenic stimulator, separated by a minimum of 90 days; and the fracture is not of the skull or vertebrae; and the fracture is not tumor related.
Covered CPT/HCPCS codes for electrical stimulation if selection criteria are met: CPT 20974 (electrical stimulation noninvasive), CPT 20975 (invasive operative); HCPCS E0747 (electrical, noninvasive, non-spinal applications), E0748 (electrical, noninvasive, spinal applications), E0749 (electrical, surgically implanted).
Examples of covered diagnoses (ICD-10 codes listed as covered if selection criteria are met) include spondylolisthesis (M43.10-M43.19), malunion of fracture, nonunion of fracture, congenital pseudarthrosis/other congenital malformations of limbs (Q74.0-Q74.9), congenital spondylolisthesis (Q76.2), Colles fracture (S52.531+ - S52.539+), scaphoid fracture (S62.001+ - S62.036+), fractures of tibia (S82.101+ - S82.299+), medial malleolus, fibula fractures, pilon fracture of tibia, Jones (5th metatar [...]
Electrical stimulation for spine fusion when any of the following indications are met: failed spinal fusion where a minimum of nine months has elapsed since the last surgery; or following a multilevel spinal fusion surgery; or following spinal fusion surgery where there is a history of a previously failed spinal fusion at the same site (Medicare note: a multilevel spinal fusion is one which involves 3 or more vertebrae).
Non-spinal electrical stimulation (Medicare-supported indications): nonunion of a long bone fracture, defined as radiographic evidence that fracture healing has ceased for three or more months prior to starting treatment with the osteogenesis stimulator; or failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last surgery; or congenital pseudarthrosis.
FDA-approved/cleared uses discussed in the evidence base: low-intensity pulsed ultrasound (SAFHS/Exogen) was FDA-approved to accelerate healing of new fractures in the tibial diaphysis and Colles' (distal radius) fractures in adults (clinical trials began treatment within 7 days of injury).

2 Active Policies

AETNA-CPB-0107, Chiropractic Services

AETNA-CPB-0343, Bone Growth Stimulators

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Q74.9, Unspecified congenital malformation of limb(s)