Does S46.999S require prior authorization?

No, S46.999S does not require prior authorization (high confidence). Covered without prior authorization.

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`S46.999S`, Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, unspecified arm, sequela

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Clinical trial/reporting deficiencies noted: many studies lacked standardized reporting of laser parameters, allocation concealment, blinding, withdrawals, and treatment protocols — implying that documentation of laser parameters (wavelength, power, J/cm2, duration, frequency) would be important though not formally required in this text.
No documentation requirements, billing criteria, ICD-10/CPT codes, or explicit medical necessity documentation instructions are specified in this document.
Clinical notes supporting medical necessity and that the patient meets any applicable selection criteria (the CPB references 'selection criteria' for coverage of CPT 0552T but the selection criteria text is not included in this chunk).

Documentation of the specific laser therapy modality and parameters used (device, wavelength, dosing) and treatment dates to support billing of CPT 0552T when covered.

If billed, supporting documentation to show the service is not being used for indications listed as experimental/investigational in the policy (e.g., no documentation of using LLLT for conditions in the excluded list).

No explicit 'Documentation Requirements' section provided in this document chunk; inferred documentation that would be required when covering LLLT for prevention of oral mucositis:

Key Coverage Criteria

Peri-implant mucositis (p-iM)
Aggressive periodontitis (as adjunct to scaling and root planing [SRP])
Skin burns (experimental models; LLLT to accelerate healing)
Tendon repair (animal models; LLLT often studied alone or combined with adipose-derived mesenchymal stem cells)
Brain photobiomodulation / transcranial LLLT for traumatic brain injury (TBI), Alzheimer disease (AD), depression, Parkinson disease (PD), stroke, and cognitive enhancement
Fibromyalgia (LLLT evaluated as adjuvant to exercise or vs placebo)

2 Active Policies

AETNA-CPB-0210, Phonophoresis

AETNA-CPB-0363, Cold Laser and High-Power Laser Therapies

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S46.999S, Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, unspecified arm, sequela