D16.6 — Benign neoplasm of vertebral column
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient medical record, be legible, include patient identification (complete name, dates of service), and be available to the contractor upon request.
- Medical record must identify the physician or non-physician practitioner responsible for and providing the patient's care.
- Submitted medical record must support the use of the selected diagnosis code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- Documentation must include the planned course of therapy, type and delivery of treatment, level of clinical management involved, ongoing documentation of any changes in course of treatment, and DHV as noted in the covered indications section.
Key Coverage Criteria
- Proton beam therapy is covered when the medical record documents that the service is reasonable and necessary per LCD L36658 and supports the selected diagnosis codes and planned course of therapy.
- Compounded medications for use in implantable infusion pumps may be covered by Medicare when their use meets all other criteria for services provided incident to a physician's service.
- True off-the-shelf (non‑compounded) drugs used without compounding and administered via DME may be billed using the drug-specific HCPCS code and are reimbursed under CMS ASP methodology.
- If Prialt® is implanted as a single agent in the pump, bill using HCPCS code J2278-KD.
- Compounded single-agent or combination drug formulations used in implanted infusion pumps must be billed using HCPCS code J7999-KD for reimbursement.
- CT or MRI scans of the head or neck are covered when the medical record documents the scan is reasonable and necessary for diagnostic evaluation.
20 Active Policies
L38213 — Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
J05
A57630 — Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF)
J05
A57452 — Billing and Coding: Peripheral Nerve Blocks
J06
L36850 — Peripheral Nerve Blocks
J06
Related Codes
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