S53.449D — Ulnar collateral ligament sprain of unspecified elbow, subsequent encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Initial evaluation must include an appropriate level of clinical history, examination, and medical decision-making relevant and appropriate to the individual's complaint(s) and presentation.
- Subjective historical evaluation based on standardized methods such as the '10 questions'.
- Specific standardized and non-standardized tests, assessments, and tools as appropriate.
- Interpretation and synthesis of all relevant clinical findings derived from history and physical examination for clinical decision-making.
Key Coverage Criteria
- Acupuncture may be provided as treatment when coverage for acupuncture services is available in the applicable benefit plan document and ALL medical necessity factors and ALL treatment planning/outcomes listed in the policy are met.
- Tension-type Headache
- Migraine Headache with or without Aura
- Musculoskeletal joint and soft tissue pain (e.g., hip, knee, spine) resulting in a functional deficit (e.g., inability to perform household chores, interference with job functions, loss of range of motion)
- Nausea Associated with Pregnancy (only when co-managed)
- Post-Surgical Nausea (only when co-managed)
1 Active Policy
CIGNA-CPG024 — Acupuncture - (CPG024)
Related Codes
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