Does S13.9XXA require prior authorization?

No, S13.9XXA does not require prior authorization (high confidence). Covered without prior authorization.

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`S13.9XXA`, Sprain of joints and ligaments of unspecified parts of neck, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For CPT 97032, document the type of electrical stimulation (including 'manual'/'attended'), area(s) treated, and if used for muscle weakness provide objective strength ratings and functional deficits; if used for pain provide pain rating, pain location, and effect on function.
For HCPCS G0283, document the type of electrical stimulation (e.g., TENS, IFC), area(s) treated, and objective/subjective measures showing impact on pain intensity/location/functional impact and/or swelling.
For non-implantable pelvic floor stimulation, document cognitive intactness, patient motivation, and a failed documented trial of PME training (defined as no clinically significant improvement after 4 weeks of an ordered PME plan).

For wound-related modalities (HCPCS G0281, G0329), document that the ulcer (stage III/IV pressure, arterial, diabetic, venous stasis) has not demonstrated measurable signs of healing after 30 days of conventional care and include wound measurements and treatment history.

If electrical stimulation is used beyond 12 visits as adjunctive therapy or for muscle retraining, documentation must clearly support medical necessity for continued use and improvement in function.

A logbook should be completed for each patient and include the time of the procedure, the time of each surgical manipulation of the central or peripheral nervous system, and the name, dose and times of anesthetics administered which may affect the central or peripheral nervous system or muscle.

Key Coverage Criteria

Attended/manual electrical stimulation (CPT 97032) is covered when the qualified professional provides direct 1-on-1 patient contact to apply/manualy adjust stimulation (e.g., direct motor point stimulation, FES/NMES when combined with therapeutic exercise/neuromuscular reeducation/functional activities).
Non-implantable pelvic floor electrical stimulation delivered via vaginal or anal probes (reportable as CPT 97032) is covered for stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
Unattended/supervised electrical stimulation provided as part of a therapy plan of care (HCPCS G0283) is covered for non-wound indications (e.g., TENS, IFC, cyclical muscle stimulation) when used to control pain and/or swelling and when objective/subjective improvement is documented.
Electromagnetic therapy (HCPCS G0329) is covered for chronic stage III and IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.
Unattended electrical stimulation for wound management (HCPCS G0281) is covered for chronic stage III and IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers that have not shown measurable healing after 30 days of conventional care.
Continuous intraoperative neurophysiologic monitoring (IOM) is considered medically necessary when ALL of the following criteria are met: IOM is performed by either a licensed physician trained in clinical neurophysiology (e.g., a neurologist, physiatrist) or a trained technologist who is practicing within the scope of his/her state license /certification as defined by state law or appropriate authorities and is working under the direct supervision of a physician trained in neurophysiology and i [...]

2 Active Policies

CIGNA-0509, Intraoperative Monitoring

A53065, Billing and Coding: Outpatient Physical Therapy

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S13.9XXA, Sprain of joints and ligaments of unspecified parts of neck, initial encounter