Does M54.06 require prior authorization?

No, M54.06 does not require prior authorization (low confidence). No active coverage policies found for this code.

Verity

`M54.06` — Panniculitis affecting regions of neck and back, lumbar region

ICD-10-CM

Prior Authorization

No Prior Auth Required

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

Documentation Required

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.
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.

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.
Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.
Beneficiary is under the care of a physician.
Beneficiary is receiving services under a plan of care that is established and periodically reviewed by 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

Have a follow-up question?

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

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.

The contractor may request medical records from the referring physician if the radiologist's documentation does not validate that the service is reasonable and necessary.

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

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

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

M54.06 — Panniculitis affecting regions of neck and back, lumbar region