Does S42.294B require prior authorization?

No, S42.294B does not require prior authorization (high confidence). Code is covered without prior authorization.

`S42.294B` — Other nondisplaced fracture of upper end of right humerus, initial encounter for open fracture

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Billing and coding for immunizations must follow the coverage indications, limitations, and medical necessity criteria set forth in the associated Local Coverage Determination LCD L34596 (Immunizations).
A valid, written, physician-signed and dated plan of treatment must be established prior to provision of physical therapy and must outline type, amount, frequency, duration, functional diagnosis deficits, and anticipated short- and long-term goals.
Services must be ordered by a physician and the order must be documented in the medical record.
Treatment notes must be completed per visit, be legible, objectively document findings (e.g., numeric pain scores), relate to established goals, reflect all services billed, and use consistent symbols/acronyms or provide a legend.

Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.
Beneficiary is under the care of a physician.
Beneficiary is receiving services under a plan of care that is established and periodically reviewed by a physician.
Beneficiary needs skilled nursing care on an intermittent basis, or physical therapy, or speech-language pathology, or has a continued need for occupational therapy.
Physical therapy services ordered by a physician and provided by a qualified physical therapist or under the general supervision of a qualified physical therapist are covered when reasonable and necessary to treat illness/injury or to restore or maintain function.
Physical therapy services provided as a result of a valid written, physician-signed and dated plan of treatment established prior to provision that specifies type, amount, frequency, duration, functional diagnosis deficits, and short- and long-term goals are covered.

A56900 — Billing and Coding: Immunizations

J05

L34596 — Immunizations

J05

A58873 — Billing and Coding: Tetanus Immunization

J09

A58872 — Billing and Coding: Tetanus Immunization

J12

A59877 — Billing and Coding: Total Shoulder Arthroplasty

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