M90.551 — Osteonecrosis in diseases classified elsewhere, right thigh
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Medical record must fully support medical necessity and justification and be available to Noridian upon request; typical components include history and physical, discharge summary, physician progress notes, and operative report.
- Imaging (X-ray, MRI, or CT) results must be in the record when indicated and should document specific findings supporting advanced joint disease.
- Documentation must describe knee pain and/or functional disability in context (e.g., interference with ADLs, increased pain with initiation of activity or with weight bearing).
- Documentation of conservative therapy attempts is required when appropriate, such as trial of NSAIDs or noted contraindication to NSAIDs, and/or supervised physical therapy, with evidence that ADLs remain diminished.
Key Coverage Criteria
- Total knee arthroplasty (TKA/TKR) is covered for advanced joint disease of the knee when imaging (X-ray, MRI, or CT) documents one or more of: subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, degree of joint space narrowing, avascular necrosis, or bone-on-bone articulation.
- TKA/TKR is covered when the patient has knee pain and/or functional disability that interferes with activities of daily living (ADLs) or pain that increases with initiation of activity or with weight bearing.
- TKA/TKR is covered after unsuccessful conservative (non-surgical) therapy when documentation shows a reasonable trial such as NSAIDs (or documented contraindication) and/or supervised physical therapy, with persistent ADL impairment despite non-surgical care.
- Revision or replacement TKA/TKR is covered for appropriate indications (e.g., pain, infection, malignancy, fracture) when supporting evidence is documented such as pathology reports, oncologist referral for joint malignancy, imaging for fracture, or other relevant studies.
- When infection is the indication for revision TKA/TKR, coverage requires laboratory and/or pathology reports, documentation of infection treatment, and a physician note stating it is appropriate to proceed with surgery.
- Bilateral knee replacement is covered only when all standard criteria for each knee are met and the medical record documents medical necessity for bilateral surgery and a physician discussion of significant benefits and risks with the patient.
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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