M46.01 — Spinal enthesopathy, occipito-atlanto-axial region
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- For multiple injection sites, the record must document the reason for injecting each site and substantiate that all injections were reasonable and necessary.
- The medical record must document medical necessity including relevant history, physical exam, and results of pertinent diagnostic tests or procedures supporting the indication for the injection.
- The procedure note must be legible and include techniques used, site(s) of injection, drugs with doses/volumes/concentrations, and pre- and post-procedural pain assessments.
- When a referring/ordering physician is required, the referring/ordering physician's name and NPI must be reported on the claim; claims without a valid ICD-10-CM diagnosis code will be returned as incomplete.
Key Coverage Criteria
- Injection into tendon sheaths, ligaments, ganglion cysts, carpal tunnel, or tarsal tunnel is covered when medically necessary to diagnose or treat local pain and the medical record documents the clinical reason for the injection at each site.
- Diagnostic injections to identify a painful structure are covered when performed no sooner than one week (preferably two) apart and limited to no more than two injections in the diagnostic phase.
- Therapeutic injections are covered when a patient had diagnostic injections demonstrating initial pain relief of ≥75–100% with return of function and maintains ≥50% pain relief and functional improvement for at least six weeks.
- Attended/manual electrical stimulation (CPT 97032) is covered when the qualified professional provides direct 1-on-1 patient contact to apply/manualy adjust stimulation (e.g., direct motor point stimulation, FES/NMES when combined with therapeutic exercise/neuromuscular reeducation/functional activities).
- Non-implantable pelvic floor electrical stimulation delivered via vaginal or anal probes (reportable as CPT 97032) is covered for stress and/or urge urinary incontinence in cognitively intact, motivated patients who have failed a documented 4-week trial of pelvic muscle exercise (PME) training.
- Unattended/supervised electrical stimulation provided as part of a therapy plan of care (HCPCS G0283) is covered for non-wound indications (e.g., TENS, IFC, cyclical muscle stimulation) when used to control pain and/or swelling and when objective/subjective improvement is documented.
20 Active Policies
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
A58893 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J06
L33622 — Pain Management - Injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels
J06
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