M65.961 — Unspecified synovitis and tenosynovitis, right lower leg
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- For multiple injection sites, the record must document the reason for injecting each site and substantiate that all injections were reasonable and necessary.
- The medical record must document medical necessity including relevant history, physical exam, and results of pertinent diagnostic tests or procedures supporting the indication for the injection.
- The procedure note must be legible and include techniques used, site(s) of injection, drugs with doses/volumes/concentrations, and pre- and post-procedural pain assessments.
- When a referring/ordering physician is required, the referring/ordering physician's name and NPI must be reported on the claim; claims without a valid ICD-10-CM diagnosis code will be returned as incomplete.
Key Coverage Criteria
- Injection into tendon sheaths, ligaments, ganglion cysts, carpal tunnel, or tarsal tunnel is covered when medically necessary to diagnose or treat local pain and the medical record documents the clinical reason for the injection at each site.
- Diagnostic injections to identify a painful structure are covered when performed no sooner than one week (preferably two) apart and limited to no more than two injections in the diagnostic phase.
- Therapeutic injections are covered when a patient had diagnostic injections demonstrating initial pain relief of ≥75–100% with return of function and maintains ≥50% pain relief and functional improvement for at least six weeks.
- Occupational therapy is covered for patients with migraine (G43.xx) who require training to reduce pain during basic and instrumental activities of daily living, typically completed in 3–4 sessions.
- Electrical stimulation (attended CPT 97032 or unattended HCPCS G0283) may be covered as part of a therapy plan of care to improve function when the nerve supply to the muscle is intact and atrophy is due to non-neurological disuse (e.g., post-casting, splinting, soft-tissue scarring).
- Wheelchair management training (CPT 97542) is covered for patient and/or caregiver training in transfers and propulsion when documentation ties the training to attainable functional goals.
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
L39139 — Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J06
A58893 — Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound
J06
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