Does M35.3 require prior authorization?

No, M35.3 does not require prior authorization (low confidence). No active coverage policies found for this code.

Verity

`M35.3` — Polymyalgia rheumatica

ICD-10-CM

Prior Authorization

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Documentation Required

The clinical history from the referral source must indicate the need for testing and the medical record must contain pertinent clinical information available for review upon request.
If an E/M service is separately billable, the medical record must document medical necessity for the separate E/M and the CPT must be billed with modifier 25.
When testing exceeds the reasonable maximum number of studies listed in the policy table, the physician must provide supplementary documentation justifying the additional testing.
Documentation must support the medical necessity of testing an asymptomatic contralateral limb when used to establish normative values.

Key Coverage Criteria

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).
Nerve conduction studies and/or needle EMG are covered when medically necessary to evaluate radiculopathy.
Nerve conduction studies and/or needle EMG are covered when medically necessary to evaluate mononeuropathy.
Nerve conduction studies and/or needle EMG are covered when medically necessary to evaluate polyneuropathy or mononeuropathy multiplex.
Needle EMG and nerve conduction studies are covered when medically necessary to evaluate myopathy.

20 Active Policies

L34594 — Nerve Conduction Studies and Electromyography

J05

A57478 — Billing and Coding: Nerve Conduction Studies and Electromyography

J05

A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J05

L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J05

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When repetitive stimulation neuromuscular junction testing (CPT 95937) is performed, the physician's report must document characteristics of the test including the rate of repetition of stimulation and timing of post-exercise or high-frequency stimulus measurements.

For CPT 95905 use in carpal tunnel patients, the beneficiary's diagnosis must be coded as G56.01, G56.02, or G56.03 and records should support high pre-test probability for carpal tunnel syndrome.

A57668 — Billing and Coding: Nerve Conduction Studies and Electromyography

J06

L35098 — Nerve Conduction Studies and Electromyography

J06

L39139 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J06

A58893 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J06

A59764 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J09

A59763 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J09

A57657 — Billing and Coding: Sedimentation Rate, Erythrocyte

J09

L34021 — Sedimentation Rate, Erythrocyte

J09

L39877 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J09

A59766 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J12

L39879 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J12

A57307 — Billing and Coding: Nerve Conduction Studies and Electromyography

A59374 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A56619 — Billing and Coding: Nerve Conduction Studies and Electromyography

A54969 — Billing and Coding: Nerve Conduction Studies and Electromyography

A54992 — Billing and Coding: Nerve Conduction Studies and Electromyography

M35.3 — Polymyalgia rheumatica