CPT code Description Area RVU
20526 Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel Carpal tunnel 1.93
20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”) Tendon Sheath 1.49
20551 Injection(s); single tendon origin/insertion Tendon Sheath 1.47
20552 Injection(s); single or multiple trigger point(s), one or two muscle(s) Muscle 1.33
20553 Injection(s); single or multiple trigger point(s) three or more muscle(s) Muscle 1.48
20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) Joint/Bursa 1.4
Note: the term “Morton’s neuroma” is used in this policy generically to refer to a swollen inflamed nerve in the ball of the foot, including the more specific conditions of Morton’s neuroma (lesion within the third intermetatarsal space), Heuter’s neuroma (first intermetatarsal space), Hauser’s neuroma (second intermetatarsal space) and Iselin’s neuroma (fourth intermetatarsal space). This policy applies to each.
Injection of a carpal tunnel is indicated for the patient with a mild case of the carpal tunnel syndrome if oral non-steroidal anti-inflammatory drugs (NSAIDs) and orthoses have failed or are contraindicated. Note that this procedure has its own CPT code, 20526. Injection of a tarsal tunnel is indicated for the patient with a mild case of tarsal tunnel syndrome if oral NSAIDs and orthoses have failed or are contraindicated. Though there are many similarities between this and carpal tunnel syndrome, there is as yet no specific CPT code for tarsal tunnel injection. Instructions below clarify that CPT 28899 is to be used until a more specific code becomes available.
Injection into tendon sheaths, ligaments, tendon origins or insertions, ganglion cysts, or neuromas may be indicated to relieve pain or dysfunction resulting from inflammation or other pathological changes. Proper use of this modality with local anesthetics and/or steroids should be short-term, as part of an overall management plan including diagnostic evaluation, in order to clearly identify and properly treat the primary cause. In some circumstances after diagnosis has been confirmed, injection of a sclerosing or neurolytic agent may be appropriate for longer-term management.
The signs or symptoms that justify these treatments should be resolved after one to three injections (see reference 2 below, under “Sources of Information and Basis for Decision”). Injections beyond three must be justified by the clinical record indicating a logical reason for failure of the prior therapy and why further treatment can reasonably be expected to succeed. A recurrence may justify a second course of therapy.
Injection therapies for tarsal tunnel syndromes (which include any so-called “Baxter’s injections”) do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific focus of inflammation on the foot. These therapies are not to be coded using 20550, 20551, 64450, 64640 or other assigned CPT codes. Rather, the provider of these therapies must bill with CPT code 28899 (Unlisted procedure, foot or toes), since there is not yet a CPT code that specifically addresses tarsal tunnel injection. Most specifically, the provider must not bill CPT codes 64450 or 64640 for these injections, since those codes respectively address the additional work of an injection of an anesthetic agent (nerve block), neurolytic or sclerosing agent into relatively more difficult peripheral nerves, rather than that involved in an injection of relatively easily localized areas such as a carpal tunnel, tarsal tunnel or Morton’s neuroma.
Medical necessity for injections of more than two sites at one session or for frequent or repeated injections is questionable. Such injections are likely to result in a request for medical records which must evidence careful justification of necessity.
“Dry needling” of ganglion cysts, ligaments, neuromas, tendon sheaths and their origins/insertions are non-covered procedures.
Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Note:
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Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors.
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20526©
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Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel
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20550©
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Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia’’)
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20551©
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Injection(s); single tendon origin/insertion
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20612©
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Aspiration and/or injection of ganglion cyst(s) any location
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28899©
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Unlisted procedure, foot or toes
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Note: Use 28899 for tarsal tunnel injection.
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64455©
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N block inj, plantar digit
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64632©
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N block inj, common digit
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Injections of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels and Morton’s Neuroma (CPT codes 20526, 20550, 20551, 20612 and 28899)
* Medicare does not have a National Coverage Determination (NCD) for the specific types of injections for pain listed above.
* Local Coverage Determinations (LCDs) which address these injections exist and compliance with these LCDs is required where applicable. For state-specific LCD, refer to the LCD Availability Grid (Attachment G).
* For states with no LCDs, see the Noridian LCD for Injections – Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton’s Neuroma (L34076) for coverage guidelines.
354.0
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Carpal tunnel syndrome
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355.5
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Tarsal tunnel syndrome
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355.6
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Lesion of plantar nerve
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720.0-720.2
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Ankylosing spondylopathies and other inflammatory spondylopathies
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720.81
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Inflammatory spondylopathies in diseases classified elsewhere
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720.89
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Other inflammatory spondylopathies
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720.9
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Unspecified inflammatory spondylopathy
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723.7
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Ossification of posterior longitudinal ligament in cervical region
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724.71
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Hypermobility of coccyx
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724.79
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Other disorders of coccyx
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726.0
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Adhesive capsulitis of shoulder
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726.10-726.12
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Rotator cuff syndrome of shoulder and allied disorders
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726.19
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Other specified disorders of bursae and tendons in shoulder region
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726.2
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Other affections of shoulder region not elsewhere classified
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726.30-726.33
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Enthesopathy of elbow region
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726.39
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Other enthesopathy of elbow region
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726.4
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Enthesopathy of wrist and carpus
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726.5
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Enthesopathy of hip region
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726.60-726.65
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Enthesopathy of knee
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726.69
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Other enthesopathy of knee
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726.70-726.73
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Enthesopathy of ankle and tarus
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726.79
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Other enthesopathy of ankle and tarsus
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726.8
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Other peripheral enthesopathies
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726.90-726.91
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Unspecified enthesopathy
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727.00-727.06
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Synovium and tenosynovitis
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727.09
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Other synovium and tenosynovitis
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727.1 – 727.3
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Other disorders of synovium, tendon and bursa
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727.40-727.43
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Ganglion and cyst of synovium, tendon and bursa
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727.49
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Other ganglion and cyst of synovium, tendon and bursa
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727.50 -727.51
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Rpture of synovium
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727.59
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Other rupture of synovium
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727.60-727.69
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Rupture of tendon, nontraumatic
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727.81-727.83
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Other disorders of synovium, tendon and bursa
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727.89
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Other disorders of synovium tendon and bursa
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727.9
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Unspecified disorder of synovium tendon and bursa
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728.4-728.6
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Disorders of muscle, ligament and fascia
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728.71
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Plantar fascial fibromatosis
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728.79
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Other fibromatoses of muscle ligament and fascia
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729.0-729.1
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Other disorders of soft tissues
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729.4
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Fasciitis unspecified
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733.6
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Tietze’s disease
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733.99
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Other disorders of bone and cartilage
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840.0-840.9
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Sprains and strains of shoulder and upper arm
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841.0-841.3
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Sprains and strains of elbow and forearm
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841.8-841.9
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Sprains and strains of elbow and forearm
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842.00-842.02
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Sprains and strains of wrist
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842.09
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Other wrist sprain
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842.10-842.13
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Sprains and strains of hand
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842.19
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Other hand sprain
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843.0-843.1
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Sprains and strains of hip and thigh
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843.8-843.9
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Sprains and strains of hip and thigh
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844.0-844.3
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Sprains and strains of knee and leg
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844.8-844.9
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Sprains and strains of knee and leg
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845.00-845.03
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Sprains and strains of ankle
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845.09
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Other sprains and strains of ankle
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845.10 – 845.13
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Sprains and strains of foot
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845.19
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Other foot sprain
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846.0-846.3
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Sprains and strains of sacroiliac region
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846.8-846.9
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Sprains and strains of sacroiliac region
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847.0-847.4
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Sprains and strains of other and unspecified parts of back
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847.9
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Sprain of unspecified site of back
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848.0-848.3
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Other and ill-defined sprains and strains
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848.40-848.42
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Other and ill-defined sprains and strains of sternum
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848.49
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Other sprain of sternum
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848.5
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Pelvic sprain
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848.8-848.9
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Other and ill-defined sprains and strains
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355.6*
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Lesion of plantar nerve
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Note: Use 355.6 for Morton’s metatarsalgia, neuralgia or neuroma
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355.8
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Mononeuritis of lower limb, unspecified
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355.9
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Mononeuritis of unspecified site
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729.2
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Neuralgia, neuritis and radiculitis, unspecified
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Submission of injection codes 64490–64495 (injection, paravertebral facet joint or facet joint nerve) or joint space injection codes (20600, 20605 and cpt code 20610) in addition to 20550 and/or 20551 must be supported by documentation in the medical record of the medical necessity of the separate procedure(s).
When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.
The most common symptom of Morton's neuroma is localized pain in the interspace between the third and fourth toes. It can be sharp or dull, and is worsened by wearing shoes and by walking. Pain usually is less severe when the foot is not bearing weight.
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