Does S42.295A require prior authorization?

No, S42.295A does not require prior authorization (high confidence). Code is covered without prior authorization.

`S42.295A` — Other nondisplaced fracture of upper end of left humerus, initial encounter for closed fracture

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.
Signature requirements: documentation must bear a legible identity (handwritten or electronic per state law) and the individual whose name appears is responsible for authenticity.

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.

A59877 — Billing and Coding: Total Shoulder Arthroplasty

A57311 — Billing and Coding: Physical Therapy - Home Health

A59878 — Billing and Coding: Total Shoulder Arthroplasty

L39956 — Total Shoulder Arthroplasty

L33942 — Physical Therapy - Home Health

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