Does S14.119S require prior authorization?

No, S14.119S 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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`S14.119S`, Complete lesion at unspecified level of cervical spinal cord, sequela

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

When billing J7999-KD, enter the name and total dose (mg or mcg) of each drug in Box 19 of the CMS-1500 or the appropriate electronic comment loop; if Box 19 cannot accommodate all information, attach the details to the paper claim.
If a portion of a single-dose vial is not used, submit the HCPCS code for the drug on a separate claim line and append modifier JW to indicate discarded/unused portion.
Separate payment may be made for pump refilling and/or adjustments; submit these services using the appropriate drug refill or maintenance CPT/HCPCS code that accurately describes the service rendered.

Compounded drugs are priced by the A/B MAC contractor by multiplying the contractor's price per mcg or mg by the total number of mcg or mg of each drug used; a pharmacy compounding fee may be allowed in addition to the calculated drug amount.

Providers who document use of an off-the-shelf product without compounding may continue to bill using the drug-specific HCPCS code when appropriate.

Use the listed CPT/HCPCS codes when billing for opioid drugs or procedures related to implantable pumps for chronic intractable pain: J7999-KD, E0782, E0783, E0785, E0786, J2274 (example), J2278-KD, 62327, 62350, 62351, 62355, 62361, 62362, 62365, 62367, 62368, 62369, 62370, 95990, 95991.

Key Coverage Criteria

Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.
True off-the-shelf (non‑compounded) drugs used without compounding and administered via DME may be billed using the drug-specific HCPCS code and are reimbursed under CMS ASP methodology.
If Prialt® is implanted as a single agent in the pump, bill using HCPCS code J2278-KD.
Compounded single-agent or combination drug formulations used in implanted infusion pumps must be billed using HCPCS code J7999-KD for reimbursement.
Routine foot care is covered only when the patient has one or more diagnoses listed in the LCD L33941 “ICD-10 Codes that Support Medical Necessity.”
Patients with peripheral neuropathy involving the feet (without vascular impairment) are covered when billed with the Group 3 ICD-10 codes appropriate for peripheral neuropathy.

12 Active Policies

A57455, Billing and Coding: Urodynamics

NGS-J6-L35098, Nerve Conduction Studies and Electromyography

A57668, Billing and Coding: Nerve Conduction Studies and Electromyography

NGS-J6-L33576, Urodynamics

FIRST_COAST-L33941, Routine Foot Care

NGS-JK-L33576, Urodynamics

NGS-JK-L35098, Nerve Conduction Studies and Electromyography

CIGNA-0509, Intraoperative Monitoring

ANTHEM-DME.00022, Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)

A56695, Billing and Coding: Implantable Infusion Pump

A57188, Billing and Coding: Routine Foot Care

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

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S14.119S, Complete lesion at unspecified level of cervical spinal cord, sequela