Does M48.55XD require prior authorization?

No, M48.55XD does not require prior authorization (low confidence). No active coverage policies found for this code.

Verity

`M48.55XD` — Collapsed vertebra, not elsewhere classified, thoracolumbar region, subsequent encounter for fracture with routine healing

ICD-10-CM

Prior Authorization

No Prior Auth Required

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

Documentation Required

This article provides billing and coding guidelines that complement Local Coverage Determination (LCD) L37848 for Lumbar Spinal Fusion; refer to LCD L37848 for clinical medical necessity criteria.
A legible medical record must document the condition, clinical findings, relevant prior treatment, and clearly justify the necessity and reasonableness of the lumbar MRI.
The documentation must clearly support the ICD-10-CM code(s) reported on the claim.
An attending or treating physician's order, properly signed and dated, is required for each lumbar MRI test.

Key Coverage Criteria

Initial lumbar MRI is covered when the test is medically reasonable and necessary and the medical record documents clinical rationale and supports the ICD-10-CM code(s) billed.
A second lumbar MRI for the same patient is allowable when documentation shows comparative test results are needed to make a more definitive treatment decision.
Multiple scans of different body areas performed on the same day for the same patient are payable when each scan is reasonable and necessary.
T82.535S | Leakage of umbrella device, sequela
M84.38XP | Stress fracture, other site, subsequent encounter for fracture with malunion
M84.38XS | Stress fracture, other site, sequela

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

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

J06

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Radiologists and ordering physicians must include sufficient clinical information in the MRI report to justify necessity; the MRI report or clinical record must document clinical findings and relevant prior treatment.

The referring physician's medical record must support any contemplated diagnosis or treatment change derived from MRI findings and must be made available to the contractor upon request.

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

J09

L39877 — 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

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

L39116 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

L37281 — Lumbar MRI

L37848 — Lumbar Spinal Fusion

L39118 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A57207 — Billing and Coding: Lumbar MRI

L33942 — Physical Therapy - Home Health

A58867 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A56396 — Billing and Coding: Lumbar Spinal Fusion

A57206 — Billing and Coding: Lumbar MRI

A57311 — Billing and Coding: Physical Therapy - Home Health

A58865 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

M48.55XD — Collapsed vertebra, not elsewhere classified, thoracolumbar region, subsequent encounter for fracture with routine healing