Does S42.261B require prior authorization?

No, S42.261B does not require prior authorization (high confidence). Code is covered without prior authorization.

`S42.261B` — Displaced fracture of lesser tuberosity of right humerus, initial encounter for open fracture

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Influenza vaccine claims must contain HCPCS G0008 and diagnosis ICD-10 Z23.
Pneumococcal vaccine claims must contain HCPCS G0009 and diagnosis ICD-10 Z23.
When pneumococcal and influenza vaccines are given the same visit, claims should contain HCPCS G0008 AND G0009 and ICD-10 Z23.
Hepatitis B vaccine claims must contain HCPCS G0010 and diagnosis ICD-10 Z23 and documentation of patient risk status (e.g., ESRD, hemophilia, household contact, sexual/drug-use risk, healthcare worker, institutional resident/staff).

COVID-19 vaccines are covered under Medicare Part B (see CMS guidance for vaccine pricing and coding).
Seasonal influenza vaccine is covered once per flu season (use codes 90635, 90637, 90638, 90653-90657, 90660-90662, 90672-90674, 90682, 90685-90689, 90694, 90695, 90756, Q2034-Q2039).
Pneumococcal vaccine is covered as an initial dose for Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B (use codes 90670, 90671, 90677, 90732).
A different, second pneumococcal vaccine is covered when administered at least 1 year after the first pneumococcal vaccine.
Pneumococcal and seasonal influenza vaccines administered during the same visit are both covered (bill seasonal influenza and pneumococcal vaccine codes).
Hepatitis B vaccine is covered only for persons at intermediate-to-high risk (use codes 90739-90740, 90743-90744, 90746-90747, 90759).

A56900 — Billing and Coding: Immunizations

J05

L34596 — Immunizations

J05

A58873 — Billing and Coding: Tetanus Immunization

J09

A58872 — Billing and Coding: Tetanus Immunization

J12

L39956 — Total Shoulder Arthroplasty

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