Does S43.401A require prior authorization?

No, S43.401A 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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`S43.401A`, Unspecified sprain of right shoulder joint, initial encounter

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

Documentation for CPT 97010, 97018, 97022, and 97026 must reflect medical necessity and be made available to the MAC upon request.
When billing a Z-code as the diagnosis, documentation must include the orthotic/prosthetic device name, date patient received the device, and date training/teaching began.
Documentation for CPT 97542 wheelchair propulsion training must relate the training to expected, attainable functional goals for the patient and/or caregiver.

Key Coverage Criteria

CPT 97110 may be billed when treating impairments of exercise tolerance due to cardiopulmonary impairments.
CPT 97542 (wheelchair management training) may be billed for wheelchair propulsion training when the training is tied to expected functional goals attainable by the patient or caregiver.
Home health physical therapy services are appropriate when based on impairments of body structure/function and demonstrable functional limitations consistent with the related LCD.
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.

3 Active Policies

ANTHEM-MP-B094276, TRANS.00035 Therapeutic use of Stem Cells, Blood and Bone Marrow Products

A53058, Billing and Coding: Home Health Physical Therapy

A53065, Billing and Coding: Outpatient Physical Therapy

`S43.401A`, Unspecified sprain of right shoulder joint, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

Have a follow-up question?

S43.401A, Unspecified sprain of right shoulder joint, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

3 Active Policies

Related Codes

Have a follow-up question?

`S43.401A`, Unspecified sprain of right shoulder joint, initial encounter