Does S12.400B require prior authorization?

No, S12.400B does not require prior authorization (high confidence). Covered without prior authorization.

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`S12.400B`, Unspecified displaced fracture of fifth cervical vertebra, initial encounter for open fracture

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

All documentation must be maintained in the patient’s medical record, be legible, include patient identifiers and dates of service, and be made available to the contractor upon request.
Operative note must document the procedure performed and any associated or additional procedures performed at the same time, and the CPT/HCPCS code submitted must describe the service performed.
Medical record must include the performing provider’s assessment related to the complaint, relevant medical history, results of pertinent tests/procedures, and documentation to support the medical necessity of the procedure.

Key Coverage Criteria

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.
This billing and coding guidance applies to cervical fusion and related cervical-spine procedures; follow LCD L39799 for reasonable and necessary coverage criteria.
Cervical fusion is reasonable and necessary to decompress symptomatic cervical nerve root impingement when persistent or recurrent moderate or severe radicular arm pain (VAS >=4 or equivalent) has been present for at least 12 weeks during the current pain episode and there is documented failure to respond to multimodal conservative management (as tolerated) in the absence of an exception.
Cervical fusion is reasonable and necessary when nerve root compression negatively impacts activities of daily living (ADLs) and other potential pain/neurological sources have been excluded.

20 Active Policies

CGS-J15-L34056, Urodynamics

J15

CGS-J15-L36460, Bone Mass Measurement

J15

CGS-J15-L39741, Cervical Fusion

J15

CGS-J18-L34056, Urodynamics

J18

CGS-J18-L39741, Cervical Fusion

J18

CGS-J18-L36460, Bone Mass Measurement

J18

A59664, Billing and Coding: Cervical Fusion

WPS-J5-L39788, Cervical Fusion

A59632, Billing and Coding: Cervical Fusion

NGS-J6-L39770, Cervical Fusion

WPS-J8-L39788, Cervical Fusion

A59674, Billing and Coding: Cervical Fusion

FIRST_COAST-L39799, Cervical Fusion

NOVITAS-JH-L35434, Oximetry Services

NOVITAS-JH-L39793, Cervical Fusion

NOVITAS-JH-L34975, Neurophysiology Evoked Potentials (NEPs)

NOVITAS-JH-L35003, Intraoperative Neurophysiological Testing

NGS-JK-L39770, Cervical Fusion

NOVITAS-JL-L35434, Oximetry Services

NOVITAS-JL-L39793, Cervical Fusion

`S12.400B`, Unspecified displaced fracture of fifth cervical vertebra, initial encounter for open fracture

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

S12.400B, Unspecified displaced fracture of fifth cervical vertebra, initial encounter for open fracture

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`S12.400B`, Unspecified displaced fracture of fifth cervical vertebra, initial encounter for open fracture