Does G04.1 require prior authorization?

No, G04.1 does not require prior authorization (high confidence). Code is covered without prior authorization.

`G04.1` — Tropical spastic paraplegia

ICD-10-CM

No Prior Auth Required

Code is 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.
Nerve conduction studies (CPT 95907-95913) and/or needle electromyography (CPT 95860-95864, 95867-95872, 95885-95887) are covered when medically necessary to evaluate Carpal Tunnel Syndrome (unilateral).
Nerve conduction studies and/or needle EMG are covered when medically necessary to evaluate Carpal Tunnel Syndrome (bilateral).

L34594 — Nerve Conduction Studies and Electromyography

J05

L34635 — Botulinum Toxin Type A & Type B

J05

A57592 — Billing and Coding: Non-Invasive Cerebrovascular Studies

J05

A57478 — Billing and Coding: Nerve Conduction Studies and Electromyography

J05

L35486

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