Does S16.9XXA require prior authorization?

No, S16.9XXA does not require prior authorization (high confidence). Covered without prior authorization.

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`S16.9XXA`, Unspecified 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.
Margin reflex distance (MRD) of 2.5 mm or less (measured from corneal light reflex to upper eyelid margin with brows relaxed) meets criteria for ptosis surgery.
A palpebral fissure height on down-gaze of 1 mm or less (measured with ipsilateral brow relaxed and contralateral lid elevated) meets criteria for ptosis surgery.
Upper blepharoplasty or ptosis repair is medically necessary when upper eyelid or brow descent produces functional visual complaints (visual field impairment in primary gaze or down-gaze/reading).
Upper blepharoplasty is indicated for chronic eyelid dermatitis caused by redundant eyelid skin.

5 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

FIRST_COAST-L33583, Diagnostic and Therapeutic Esophagogastroduodenoscopy

A57063, Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy

`S16.9XXA`, Unspecified injury of muscle, fascia and tendon at neck level, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

S16.9XXA, Unspecified injury of muscle, fascia and tendon at neck level, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

5 Active Policies

Related Codes

Have a follow-up question?

`S16.9XXA`, Unspecified injury of muscle, fascia and tendon at neck level, initial encounter