Does Z98.1 require prior authorization?

No, Z98.1 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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`Z98.1`, Arthrodesis status

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

Claims and coding for cervical disc replacement must follow the Local Coverage Determination (LCD) L38033 and the billing/coding guidelines in this article.
For repeat procedures beyond specified intervals (e.g., beyond 12 months), submission of clinical review documentation justifying continued treatment.
For oncologic, infectious, or complex structural indications: relevant pathology/imaging reports, operative reports, prior treatments, and specialist consultation notes as applicable to demonstrate meeting of selection criteria.
For inclusion in many interbody fusion device studies: failure of conservative care (commonly documented as unresponsive to at least 6 months of conservative care).

Key Coverage Criteria

Epiduroscopy / epidural lysis of adhesions: proposed for diagnosis/treatment of intractable LBP (including failed back surgery syndrome) by visualizing and lysing adhesions and injecting medications (insufficient high-quality evidence to support routine clinical use).
Kyphoplasty (balloon-assisted vertebroplasty): restore bone height for painful osteoporotic compression fractures (OVCFs); NICE and other assessments note kyphoplasty may be a reasonable alternative to vertebroplasty for recent fractures.
Sacropasty: injection of PMMA into sacrum for sacral insufficiency fractures (SIFs) in osteoporotic patients to stabilize fracture and relieve pain (developing indication).
Vesselplasty: image-guided procedure using a containment device and PMMA to treat symptomatic vertebral compression fractures to reduce cement leakage (investigational/promise shown but limited evidence).
Microsurgical anterior foraminotomy: proposed for intractable cervical radiculopathy to remove herniated disc or bone spur via anterior approach without fusion (insufficient high-quality evidence).
Open sacroiliac fusion: proposed for SIJ dysfunction/syndrome when other non-operative treatments failed; evidence insufficient to support routine use.

5 Active Policies

ANTHEM-CG-DME-40, Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton

AETNA-CPB-0016, Back Pain - Invasive Procedures

AETNA-CPB-0009, Orthopedic Casts, Braces and Splints

AETNA-CPB-0645, Total Ankle Arthroplasty

A57021, Billing and Coding: Cervical Disc Replacement

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Z98.1, Arthrodesis status