Does M54.11 require prior authorization?

No, M54.11 does not require prior authorization (low confidence). No active coverage policies found for this code.

Verity

`M54.11` — Radiculopathy, 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

All documentation must be maintained in the patient's medical record, legible, include patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
The documentation 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 selected ICD-10-CM code(s), the submitted CPT/HCPCS code must describe the service performed, and the record must clearly document medical necessity, the indication for ordering the test, and a clear diagnostic impression.
If documentation is requested, providers must submit a hard copy of waveforms and/or a complete written report with interpretation sufficient to support that the test was medically reasonable and necessary.

Key Coverage Criteria

Nerve conduction studies (NCS) without needle EMG (NEMG) are allowed for individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome when one of the following ICD-10-CM codes is reported: G56.01, G56.02, G56.03, G56.11, G56.12, G56.13, G56.21, G56.22, G56.23, G57.51, G57.52, or G57.53.
NCS without NEMG is allowed for individuals with significant lymphedema in the affected extremity when ICD-10-CM code I89.0 is reported in addition to the primary diagnosis.
NCS without NEMG is allowed for individuals treated with anticoagulants when ICD-10-CM code Z79.01 or Z79.02 is reported in addition to the primary diagnosis.
Electrodiagnostic testing (EMG and/or nerve conduction studies) is indicated for evaluation of suspected carpal tunnel syndrome.
EMG and/or nerve conduction studies are indicated for evaluation of suspected radiculopathy.
EMG and/or nerve conduction studies are indicated for evaluation of suspected mononeuropathy (single-nerve entrapment or injury).

20 Active Policies

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

J05

A59664 — Billing and Coding: Cervical Fusion

J05

L34594 — Nerve Conduction Studies and Electromyography

J05

L39788 — Cervical Fusion

J05

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Reports must document normal findings and abnormalities with the nerves and muscles tested, presence and type of spontaneous activity, characteristics of voluntary unit potentials, interpretation, and the expected normal value range for the specific EDX device.

If analogous testing was previously performed, documentation must reference the date of prior testing, the results, and subsequent management based on those findings.

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

A57478 — Billing and Coding: Nerve Conduction Studies and Electromyography

J05

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

L35098 — Nerve Conduction Studies and Electromyography

J06

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

J06

A59632 — Billing and Coding: Cervical Fusion

J06

L39770 — Cervical Fusion

J06

L34859 — Nerve Conduction Studies and Electromyography

J09

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

J09

L39799 — Cervical Fusion

J09

L39877 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J09

A59674 — Billing and Coding: Cervical Fusion

J09

A57123 — Billing and Coding: Nerve Conduction Studies and Electromyography

J09

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

J09

L34975 — Neurophysiology Evoked Potentials (NEPs)

J12

M54.11 — Radiculopathy, occipito-atlanto-axial region