Does S12.121A require prior authorization?

No, S12.121A does not require prior authorization (high confidence). Covered without prior authorization.

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`S12.121A`, Other nondisplaced dens fracture, initial encounter for closed fracture

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

All services ordered or rendered to Medicare beneficiaries must be signed; providers/suppliers must notify beneficiaries in writing prior to rendering the service if aware the test/item/procedure may not be covered.
A valid ICD-10-CM diagnosis code that best describes the patient's condition must be reported on the claim; claims without a valid ICD-10-CM code will be returned as incomplete under Section 1833(e).
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

The patient's medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.

For diagnostic tests, report the test result if known; if result is not known, report the symptoms that prompted performance of the test.

When services are likely to be non-covered, use an Advance Beneficiary Notice (ABN) and the appropriate modifier (-GA, -GX, -GY, or -GZ) as applicable; for Part A claims with GA, include occurrence code 32 and the date of the ABN and have Form CMS-R-131 signed by the beneficiary.

Key Coverage Criteria

Bone mass measurement tests are covered when ordered by the treating physician or a qualified non-physician practitioner authorized by state law.
An initial bone mass measurement is covered (Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless of sites studied).
A DXA confirmatory test may be performed and covered as a baseline for future monitoring (exception to the 'one type only' rule).
CPT code 77082 (vertebral fracture assessment) is covered when medically necessary, with symptoms documented and when results are anticipated to be used in patient management.
CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
Coverage requires documentation supporting clinical indication such as history and physical exam findings, laboratory results, and signs or symptoms that justify the diagnostic test.

12 Active Policies

CGS-J15-L36460, Bone Mass Measurement

J15

CGS-J18-L36460, Bone Mass Measurement

J18

WPS-J5-L34623, Intraoperative Neurophysiological Testing

A57604, Billing and Coding: Intraoperative Neurophysiological Testing

WPS-J8-L34623, Intraoperative Neurophysiological Testing

NOVITAS-JH-L35434, Oximetry Services

NOVITAS-JL-L35434, Oximetry Services

A57205, Billing and Coding: Oximetry Services

A59040, Billing and Coding: Bone Mass Measurement

A57132, Billing and Coding: Bone Mass Measurement

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

A57311, Billing and Coding: Physical Therapy - Home Health

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S12.121A, Other nondisplaced dens fracture, initial encounter for closed fracture