Does T84.012A require prior authorization?

No, T84.012A does not require prior authorization (high confidence). Covered without prior authorization.

`T84.012A`, Broken internal right knee prosthesis, initial encounter

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

For knee orthoses with adjustable knee joints or prefabricated Swedish type (HCPCS L1832, L1833, L1850) the medical record must document a physical examination of the affected knee(s) including the joint laxity test(s) performed and a description of exam findings that support objective joint laxity.
For single or double upright, adjustable flexion/extension knee orthoses with medial-lateral and rotation control (HCPCS L1843, L1844, L1845, L1846, L1851, L1852) used for ambulatory beneficiaries with knee instability, medical records must document ambulatory status and a physical exam of the affected knee(s) including joint laxity test(s) performed and description of findings supporting objective joint laxity.
For the same single/double upright orthoses (L1843, L1844, L1845, L1846, L1851, L1852) when used to manage pain affecting mobility/function due to medial or lateral tibiofemoral osteoarthritis, records must include ambulatory status; pain symptoms or mobility/functional reduction; physical exam of the affected knee(s); an imaging report describing arthritic changes consistent with medial/lateral tibiofemoral osteoarthritis; and the beneficiary's willingness to use the orthosis.

A knee orthosis is covered when it is a rigid or semi-rigid device used to support a weak or deformed knee or to restrict or eliminate motion in a diseased or injured knee and the device meets the reasonable and necessary requirements of the related Local Coverage Determination and all statutory/regulatory requirements.
Both off-the-shelf (OTS) and custom-fit knee orthoses are treated as prefabricated braces for coding and may be covered provided the coding accurately reflects whether only minimal self-adjustment was required at final fitting per 42 CFR §414.402.
If the orthosis is provided prior to an inpatient hospital admission or Part A SNF stay and the medical necessity begins during that inpatient stay, payment is included in the hospital or SNF payment (do not submit claim to the DME MAC).
An orthosis provided within two days prior to discharge and not needed for inpatient treatment but intended for home use is eligible for DME MAC coverage if medically necessary after discharge.
Coverage for lower extremity major joint replacement (hip and knee) is subject to the reasonable and necessary requirements of Local Coverage Determination L36007; services meeting LCD L36007 criteria are covered.
Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.

CGS-J15-L40232, Total Joint Arthroplasty

J15

CGS-J18-L40232, Total Joint Arthroplasty

J18

A59811, Billing and Coding: Total Joint Arthroplasty

WPS-J5-L39911, Total Joint Arthroplasty

WPS-J8-L39911, Total Joint Arthroplasty

Ask Backwork about documentation requirements, denial risks, or coverage in your state.