Does M43.6 require prior authorization?

No, M43.6 does not require prior authorization (low confidence). No active coverage policies found for this code.

Verity

`M43.6` — Torticollis

ICD-10-CM

Prior Authorization

No Prior Auth Required

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

Documentation Required

Medical record must document medical necessity, relevant history, physical exam, and results of pertinent diagnostic tests supporting botulinum toxin use and must reference the covered diagnosis.
For spastic conditions other than upper/lower-limb spasticity, blepharospasm, hemifacial spasm, cervical dystonia or other focal dystonias, documentation must state unresponsiveness to conventional treatment and include dosage, injection site(s), frequency, EMG necessity (if used), and effectiveness.
Claims must report referring/ordering physician name and NPI when required by the service, and a valid ICD-10-CM code that best describes the treated condition must be present on the claim.
Documentation must show exact drug dosage administered, reason for unavoidable wastage, and amount discarded; split-vial use must document amounts given to each patient and pro rata wastage calculation details.

Key Coverage Criteria

Botulinum toxin injections are covered for limb spasticity, including upper- and lower-limb spasticity, when medically necessary.
Botulinum toxin injections are covered for blepharospasm when medically necessary.
Botulinum toxin injections are covered for hemifacial spasm when medically necessary.
Botulinum toxin injections are covered for cervical dystonia when medically necessary.
Botulinum toxin injections are covered for other focal dystonias when medically necessary.
Electromyography (EMG) guidance for injection needle placement is covered when medically necessary and billed with appropriate CPT codes (e.g., 95873; 95874 when not billed with 95873).

20 Active Policies

A57474 — Billing and Coding: Botulinum Toxin Type A & Type B

J05

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

J05

L39908 — Botulinum Toxin Injections

J05

L34594 — Nerve Conduction Studies and Electromyography

J05

Have a follow-up question?

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

When billing discarded drug amounts to Medicare, use -JW modifier on a separate line with appropriate units rounded to the nearest unit such that total billed does not exceed vial contents; effective July 1, 2023 use JZ when no discarded amount.

Providers must maintain documentation of reconstitution and waste and be prepared to supply documentation or peer-reviewed literature upon contractor request for case-by-case determinations.

— Botulinum Toxin Type A & Type B

A59808 — Billing and Coding: Botulinum Toxin Injections

J05

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

J05

A57478 — Billing and Coding: Nerve Conduction Studies and Electromyography

J05

L33646 — Botulinum Toxins

J06

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

J06

L35098 — Nerve Conduction Studies and Electromyography

J06

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

J06

A57668 — Billing and Coding: Nerve Conduction Studies and Electromyography

J06

A52848 — Billing and Coding: Botulinum Toxins

J06

A59706 — Billing and Coding: Botulinum Toxin Injections

J06

L39877 — 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

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

J09

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

J12

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

J12

M43.6 — Torticollis