Does S42.491B require prior authorization?

No, S42.491B does not require prior authorization (high confidence). Covered without prior authorization.

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`S42.491B`, Other displaced fracture of lower end of right humerus, initial encounter for open fracture

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Billing and coding for immunizations must follow the coverage indications, limitations, and medical necessity criteria set forth in the associated Local Coverage Determination LCD L34596 (Immunizations).
All documentation must be maintained in the patient medical record and made available to the contractor upon request, with every page legible and containing appropriate patient identification (e.g., full name, dates of service).
The record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.

The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.

All documentation must be maintained in the patient's medical record and made available to the contractor upon request.

Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).

Key Coverage Criteria

Tetanus immunization is covered when given for a wound or documented direct exposure to Clostridium tetani (injury-related or exposure-related prophylaxis).
Tetanus immunization is covered when given for an injury or direct exposure to tetanus (i.e., wound management or exposure prophylaxis).
Preventive immunizations are covered for pneumococcal, hepatitis B, and influenza vaccines.
When the patient has not been previously immunized for rabies, coverage includes RIG (half IM and half wound on day 0) plus HDCV on days 0, 3, 7, 14, and 28.
Vaccinations are covered only when directly related to treatment of an injury or direct exposure to a disease/condition listed in this policy.
Tdap or Td vaccines are covered when given for an acute injury in a person who is incompletely immunized for tetanus.

5 Active Policies

WPS-J5-L34596, Immunizations

A56900, Billing and Coding: Immunizations

WPS-J8-L34596, Immunizations

A58873, Billing and Coding: Tetanus Immunization

A58872, Billing and Coding: Tetanus Immunization

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S42.491B, Other displaced fracture of lower end of right humerus, initial encounter for open fracture