M54.59 — Other low back pain
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Medical necessity for each test must be documented in the patient's medical record as required by LCD L35006.
- 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 and dates of service.
- Documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
Key Coverage Criteria
- Urine drug testing (UDT) and drugs-of-abuse testing are covered when reasonable and necessary per LCD L35006 and ordered on an individual patient basis by the treating clinician with medical-record documentation of medical necessity.
- Patients with a documented diagnosis consistent with substance use disorder (SUD) may qualify for an exception to the standard presumptive UDT annual limits.
- Controlled substance monitoring and drugs-of-abuse testing are covered when individually ordered by the treating clinician and meet the reasonable and necessary requirements specified in LCD L36393.
- Duplex scanning is covered only when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33674.
- Trigger point injections are covered when they meet the reasonable and necessary clinical criteria specified in Local Coverage Determination L35010.
- Coverage for amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications is determined by Local Coverage Determination L39139; consult LCD L39139 for specific clinical indications and thresholds.
20 Active Policies
L39624 — Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
A59434 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J05
L39713 — Trigger Point Injections
J05
A59553 — Billing and Coding: Trigger Point Injections
J05
Related Codes
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