Does Q65.1 require prior authorization?

No, Q65.1 does not require prior authorization (high confidence). Code is covered without prior authorization.

`Q65.1` — Congenital dislocation of hip, bilateral

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
Every page of the medical record must be legible and include appropriate patient identification information such as complete name and dates of service.
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the patient’s care.
The submitted medical record must support the use of the selected ICD-10-CM code(s).

Coverage for lower extremity major joint replacement (hip and knee) is subject to the reasonable and necessary requirements of Local Coverage Determination L36007; services meeting LCD L36007 criteria are covered.
Total knee arthroplasty (TKA) is considered medically reasonable and necessary only when at least three of the knee-specific indications listed in this LCD are met.
Total hip arthroplasty (THA) is considered medically reasonable and necessary only when at least three of the hip-specific indications listed in this LCD are met.
Advanced joint disease of the knee demonstrated by radiographic or MRI evidence (e.g., joint surface deterioration, subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis) is an indication for TKA.
Advanced joint disease of the hip demonstrated by radiographic or MRI evidence (e.g., subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis) is an indication for THA.
History of unsuccessful appropriate conservative (non-surgical) therapy clearly documented in the pre-procedure medical record is required for TKA consideration; non-surgical management is usually implemented for 3 months or more.

A56796 — Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee)

J12

L36007 — Lower Extremity Major Joint Replacement (Hip and Knee)

J12

Ask Verity about documentation requirements, denial risks, or coverage in your state.