M72.2 — Plantar fascial fibromatosis
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Specified HCPCS codes require a face-to-face encounter and Written Order Prior to Delivery (WOPD) per Final Rule 1713; failure to obtain WOPD prior to delivery results in denial.
- Supplier must include diagnosis code(s) on the claim line for HCPCS L4396, L4397, L4392 and L4631.
- For custom-fabricated orthoses, the supplier's records must document medical necessity for a custom device rather than a prefabricated orthosis and be available upon request.
- Supplier records must show the product specified by the treating practitioner, the treating practitioner's medical record that justifies the type of product (prefabricated versus custom), and detailed justification for the HCPCS code billed.
Key Coverage Criteria
- Ankle-foot orthoses (AFO) and knee-ankle-foot orthoses (KAFO) are covered when they are rigid or semi-rigid devices used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body.
- Coverage requires that reasonable and necessary (R&N) medical necessity criteria in the related Local Coverage Determination (LCD) are met for the beneficiary's diagnosis or functional deficit.
- An orthosis provided within two days prior to discharge to home is eligible for DME MAC coverage if it is medically necessary after discharge and was not needed for inpatient treatment or rehabilitation.
- 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.
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
L40268 — Pain Management - Injection of tendon sheaths, ligaments, bursa, and ganglion cysts
J06
A52863 — Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels
J06
Related Codes
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