Does S16.8XXA require prior authorization?

No, S16.8XXA does not require prior authorization (high confidence). Covered without prior authorization.

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`S16.8XXA`, Other specified injury of muscle, fascia and tendon at neck level, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

List the appropriate CPT code for the procedure and include any applicable modifiers; adhere to Medicare global surgery and CCI (correct coding initiative) rules for eyelid surgeries.
Submit physicians' services and diagnostic tests with a diagnosis code that supports medical necessity and code to the greatest level of specificity (full digit completeness).
Use the diagnosis code based on diagnostic test results as the primary diagnosis; if test results are normal or inconclusive, use the diagnosis code for the sign or symptom that prompted the test as the primary diagnosis.

When a patient requests submission of cosmetic services to Medicare, report with modifier GY and place ICD-10 code Z41.1 in the first diagnosis position on the claim; consider issuing a Notice of Exclusion from Medicare Benefits (NEMB) as appropriate.

Key Coverage Criteria

Blepharoplasty, blepharoptosis repair, or brow lift is covered when documented signs or symptoms of a functional abnormality of the upper eyelids are present as defined by the associated LCD (L34528).
Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
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.
Acupuncture may be provided as treatment when coverage for acupuncture services is available in the applicable benefit plan document and ALL medical necessity factors and ALL treatment planning/outcomes listed in the policy are met.
Tension-type Headache

7 Active Policies

WPS-J5-L34528, Blepharoplasty, Blepharoptosis and Brow Lift

A56908, Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift

WPS-J8-L34528, Blepharoplasty, Blepharoptosis and Brow Lift

A57063, Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

FIRST_COAST-L33583, Diagnostic and Therapeutic Esophagogastroduodenoscopy

CIGNA-CPG024, Acupuncture

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

`S16.8XXA`, Other specified injury of muscle, fascia and tendon at neck level, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

S16.8XXA, Other specified injury of muscle, fascia and tendon at neck level, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

`S16.8XXA`, Other specified injury of muscle, fascia and tendon at neck level, initial encounter