Does R51.0 require prior authorization?

No, R51.0 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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`R51.0`, Headache with orthostatic component, not elsewhere classified

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

Claims must report the precise level(s) of subluxation as the primary diagnosis and the neuromusculoskeletal condition necessitating treatment as the secondary diagnosis.
Each claim must include date of initiation of the course of treatment, symptom/secondary diagnosis code(s), subluxation/primary diagnosis code(s), date of service, place of service, and procedure code; missing items may cause denial or delay.
Diagnosis codes supporting medical necessity must be submitted with each claim; progress notes need not accompany each claim but must be maintained and available upon request.

Key Coverage Criteria

Medicare covers manual manipulation of the spine (chiropractic manipulative treatment) for treatment of spinal subluxation using CPT codes 98940, 98941, or 98942 when medically necessary.
Subluxation must be demonstrated and documented (by x-ray or physician/chiropractic exam) with the problem/complaint addressed and the precise level of each subluxation treated specified in the medical record.
Active/corrective treatment for acute or chronic subluxation requires use of the AT modifier on claims.
Clinical findings supporting subluxation should follow PART elements (Pain, Asymmetry/misalignment, Range of motion abnormality, Tissue/tone changes) documented by observation, palpation, imaging, or measurement as appropriate.
Visual field testing is covered when billed to the Part A or Part B MAC with a valid ICD-10-CM diagnosis code that best describes the patient’s condition and when the service is reasonable and necessary.
For diagnostic visual field tests, report the test result on the claim if known; if the result is not known, report the signs or symptoms that prompted the test.

18 Active Policies

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J18-L34394, Visual Fields Testing

J18

FIRST_COAST-L34021, Sedimentation Rate, Erythrocyte

FIRST_COAST-L33933, Peripheral Nerve Blocks

A57657, Billing and Coding: Sedimentation Rate, Erythrocyte

AMBETTER-CP.MP.155, EEG in the Evaluation of Headache

CIGNA-CPG024, Acupuncture

AETNA-CPB-0135, Acupuncture and Dry Needling

AETNA-CPB-0707, Headaches: Invasive Procedures

A56273, Billing and Coding: Chiropractic Services

A56799, Billing and Coding: Visual Fields Testing

A57204, Billing and Coding: MRI and CT Scans of the Head and Neck

A57497, Billing and Coding: Chest X-Ray Policy

A57788, Billing and Coding: Peripheral Nerve Blocks

ANTHEM-SURG.00144, Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia

ANTHEM-SURG.00112, Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices (and Related Procedures)

ANTHEM-SURG.00096, Surgical and Ablative Treatments for Chronic Headaches

ANTHEM-CG-SURG-73, Balloon Sinus Ostial Dilation

`R51.0`, Headache with orthostatic component, not elsewhere classified

Prior Authorization

Documentation Required

Key Coverage Criteria

18 Active Policies

Related Codes

Have a follow-up question?

R51.0, Headache with orthostatic component, not elsewhere classified

Prior Authorization

Documentation Required

Key Coverage Criteria

18 Active Policies

Related Codes

Have a follow-up question?

`R51.0`, Headache with orthostatic component, not elsewhere classified