Z87.312 — Personal history of (healed) stress fracture
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of failure to respond to appropriate conservative therapies (examples provided: rest, ice application, and medications).
- Medical record evidence supporting that selection criteria were met prior to billing code 0101T (i.e., clinical notes, prior treatment attempts, imaging reports specifying deposit size and location).
- If claiming coverage under the CPB, supporting clinical documentation must link the ICD-10 diagnosis to the policy-covered indication (i.e., calcific tendinopathy of shoulder meeting the above criteria) and should avoid coding that the policy explicitly lists as not covered (e.g., subacromial impingement syndrome).
- None specified in this document. The text summarizes clinical studies and systematic reviews but does not provide insurer coverage documentation requirements (no required clinical notes, imaging, prior conservative therapy documentation, or ICD-10/CPT code lists are given in this excerpt).
Key Coverage Criteria
- Tendon injuries and general tendinopathies
- Achilles tendinopathy (insertional and chronic Achilles tendinopathy)
- Medial epicondylitis
- Plantar fasciitis
- Greater trochanteric pain syndrome
- Nonunions and fracture healing (including acute fractures)
2 Active Policies
AETNA-CPB-0649 — Extracorporeal Shock-Wave Therapy for Musculoskeletal Indications and Soft Tissue Injuries
ANTHEM-CG-LAB-11 — CG-LAB-11 Vitamin D Testing
Related Codes
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