Does M54.05 require prior authorization?

No, M54.05 does not require prior authorization (low confidence). No active coverage policies found for this code.

Verity

`M54.05` — Panniculitis affecting regions of neck and back, thoracolumbar region

ICD-10-CM

Prior Authorization

No Prior Auth Required

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

Documentation Required

All documentation must be maintained in the patient's medical record and made available to the contractor upon request; every page must be legible and include patient identification (complete name and dates of service).
The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
The submitted medical record must support the use of the selected ICD-10-CM code(s).
The submitted CPT/HCPCS code must accurately describe the service performed.

Key Coverage Criteria

Injection of trigger points is covered only when services meet the reasonable and necessary requirements of Local Coverage Determination L33912.
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.
Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.
Beneficiary is under the care of a physician.

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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The medical record must clearly indicate the number of injections given per session and the anatomic site(s) injected.

The medical record must clearly document the medical necessity for repeated trigger point injections; when frequent injections are required the record must state the clinical reason for repetition.

A59764 — 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

A59763 — 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

A57114 — Billing and Coding: Injection of Trigger Points

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

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

L39575 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

L34220 — Lumbar MRI

L34427 — Outpatient Occupational Therapy

L34428 — Outpatient Physical Therapy

L34560 — Home Health Occupational Therapy

L34564 — Home Health Physical Therapy

M54.05 — Panniculitis affecting regions of neck and back, thoracolumbar region