Does Z87.828 require prior authorization?

No, Z87.828 does not require prior authorization (high confidence). Covered without prior authorization.

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`Z87.828`, Personal history of other (healed) physical injury and trauma

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Implied/observed documentation in the evidence base (examples of measures used in studies which could be relevant documentation): objective outcome measures such as 6-minute walk test, stair climbing power, WOMAC, Berg Balance Scale, Timed Up and Go, gait speed measures, Functional Independence measures — documentation of baseline impairment and response to therapy is emphasized in the background and study summaries.
Medical record must show objective loss of joint motion, strength, or mobility (examples: degrees of motion, strength grades, levels of assistance).
Documentation that aquatic therapy is being used to restore function lost or reduced by a specific disease or injury (i.e., not for maintenance when no improvement or decline is occurring).
Documentation when aquatic therapy is required because member cannot perform land-based exercises effectively, or when aquatic therapy facilitates progress to land-based exercise or increased function.

Key Coverage Criteria

Other forms of exercise therapy may be necessary in addition to aquatic therapy when the member cannot perform land-based exercises effectively to treat his/her condition without first undergoing the aquatic therapy, or when aquatic therapy facilitates progress to land-based exercise or increased function.
Applications/clinical scenarios discussed in the evidence base (documented as studied indications or populations receiving aquatic therapy) include: knee and hip osteoarthritis; rehabilitation after total knee replacement (TKR) and total hip/knee arthroplasty; developmental coordination disorder in children; juvenile idiopathic arthritis (JIA); fibromyalgia; chronic obstructive pulmonary disease (COPD); autism spectrum disorder (social/behavioral outcomes); neurological conditions (stroke rehabi [...]
Specific technique references included as investigated: Halliwick method, aquatic treadmill training (ATT), aquatic treadmill walking, Ai Chi, WATSU (WaterShiatsu), Aqua Lymphatic Therapy (ALT), crenobalneotherapy, nano-bubble hydrotherapy (emerging/experimental).
Aquatic therapy (hydrotherapy, pool therapy) is considered medically necessary for musculoskeletal conditions.
Aquatic therapy when used to restore a member's level of function lost or reduced by a specific injury or illness (e.g., loss or restriction of joint motion, strength, mobility, or function).
Aquatic therapy when the member cannot perform land-based exercises effectively to treat his/her condition without first undergoing aquatic therapy.

2 Active Policies

AETNA-CPB-0174, Pool Therapy, Aquatic Therapy or Hydrotherapy

AETNA-CPB-0198, Work Hardening Programs

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Z87.828, Personal history of other (healed) physical injury and trauma