TerelNewton.com - ++ MEDICAL NECESSITY

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Medical Necessity Outline

I. HEAD

A. Post-Concussion Syndrome / Traumatic Brain Injury (INJURY)

- ICD-10: S06.0X0A (Concussion w/o LOC, initial); F07.81 (Post-concussive syndrome)

- Diagnostics: MRI Brain w/o contrast (70551), CT Head (70450), Neurocognitive testing (96116)

- Treatments: Cognitive rehabilitation (97530), Pharmacologic management (E/M)

B. Chronic Migraine (NON-INJURY)

- ICD-10: G43.709 (Chronic migraine w/o aura, not intractable); G43.719 (intractable)

- Diagnostics: MRI Brain w/o contrast (70551)

- Treatments: OnabotulinumtoxinA injection for migraine (64615 + J0585), Occipital nerve block (64405), Greater occipital nerve block (64405)

C. Occipital Neuralgia (INJURY or NON-INJURY)

- ICD-10: M54.81 (Occipital neuralgia)

- Diagnostics: MRI cervical spine w/o contrast (72141)

- Treatments: Occipital nerve block (64405), Radiofrequency ablation (64999), Trigger point injection (20552)

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II. CERVICAL SPINE / NECK

D. Whiplash / Cervical Strain (INJURY)

- ICD-10: S13.4XXA (Sprain of ligaments of cervical spine, initial); S13.4XXD (subsequent)

- Diagnostics: X-ray cervical spine (72050), MRI cervical spine w/o contrast (72141)

- Treatments: Trigger point injections (20552/20553), Cervical facet joint injection (64490), Physical therapy (97110/97140)

E. Cervical Disc Herniation with Radiculopathy (INJURY or NON-INJURY)

- ICD-10: M50.121 (C4-C5 w/ radiculopathy); M50.122 (C5-C6); M50.123 (C6-C7)

- Diagnostics: MRI cervical spine w/o contrast (72141), EMG/NCS (95860, 95907-95913)

- Treatments: Cervical interlaminar ESI (62320/62321), Cervical transforaminal ESI (64479), ACDF (22551/22552)

F. Cervical Spondylosis with Myelopathy (NON-INJURY)

- ICD-10: M47.12 (Spondylosis w/ myelopathy, cervical)

- Diagnostics: MRI cervical spine w/ & w/o contrast (72156), EMG/NCS (95860, 95907-95913)

- Treatments: Cervical ESI (62320/62321), Cervical laminectomy (63015), ACDF (22551)

G. Cervical Radiculopathy (INJURY or NON-INJURY)

- ICD-10: M54.12 (Radiculopathy, cervical region)

- Diagnostics: MRI cervical spine (72141), EMG/NCS (95860, 95907-95913)

- Treatments: Cervical ESI (62320/62321), Cervical transforaminal ESI (64479), Cervical medial branch block (64490), Cervical RFA (64633)

H. Cervical Facet Syndrome (INJURY or NON-INJURY)

- ICD-10: M47.812 (Spondylosis w/o myelopathy or radiculopathy, cervical)

- Diagnostics: MRI cervical spine (72141), Fluoroscopy-guided diagnostic medial branch block (64490 + 77003)

- Treatments: Cervical medial branch block (64490/64491), Cervical radiofrequency ablation (64633/64634)

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III. THORACIC SPINE

I. Thoracic Radiculopathy / Pain (INJURY or NON-INJURY)

- ICD-10: M54.14 (Radiculopathy, thoracic); M54.6 (Pain in thoracic spine)

- Diagnostics: MRI thoracic spine w/o contrast (72146), X-ray thoracic spine (72070)

- Treatments: Thoracic ESI (62320/62321), Thoracic facet injection (64490), Trigger point injections (20552/20553)

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IV. LUMBAR SPINE / LOW BACK

J. Lumbar Disc Herniation with Radiculopathy (INJURY or NON-INJURY)

- ICD-10: M51.16 (Disc disorder w/ radiculopathy, lumbar); M51.17 (lumbosacral)

- Diagnostics: MRI lumbar spine w/o contrast (72148), EMG/NCS (95861, 95907-95913)

- Treatments: Lumbar interlaminar ESI (62322/62323), Lumbar transforaminal ESI (64483/64484), Lumbar microdiscectomy (63042)

K. Lumbar Spinal Stenosis (NON-INJURY)

- ICD-10: M48.06 (Spinal stenosis, lumbar); M48.07 (lumbosacral)

- Diagnostics: MRI lumbar spine w/o contrast (72148), CT lumbar spine (72131), X-ray lumbar spine (72110)

- Treatments: Lumbar ESI (62322/62323), Lumbar transforaminal ESI (64483), Lumbar decompression/laminectomy (63047)

L. Lumbar Radiculopathy / Sciatica (INJURY or NON-INJURY)

- ICD-10: M54.16 (Radiculopathy, lumbar); M54.17 (lumbosacral); M54.31/M54.32 (Sciatica R/L)

- Diagnostics: MRI lumbar spine (72148), EMG/NCS (95861, 95907-95913)

- Treatments: Lumbar ESI (62322/62323), Lumbar transforaminal ESI (64483/64484)

M. Lumbar Facet Syndrome / Spondylosis (INJURY or NON-INJURY)

- ICD-10: M47.816 (Spondylosis w/o myelopathy, lumbar); M47.817 (lumbosacral)

- Diagnostics: MRI lumbar spine (72148), Fluoroscopy-guided diagnostic medial branch block (64493 + 77003)

- Treatments: Lumbar medial branch block (64493/64494), Lumbar radiofrequency ablation (64635/64636)

N. Low Back Pain / Vertebrogenic Pain (INJURY or NON-INJURY)

- ICD-10: M54.50 (Low back pain, unspecified); M54.51 (Vertebrogenic low back pain); M54.59 (Other low back pain)

- Diagnostics: X-ray lumbar spine (72100/72110), MRI lumbar spine (72148)

- Treatments: Trigger point injections (20552/20553), Physical therapy (97110/97140), Basivertebral nerve ablation (0741T for M54.51)

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V. SACROILIAC JOINT / PELVIS

O. Sacroiliac Joint Dysfunction (INJURY)

- ICD-10: S33.6XXA (Sprain of sacroiliac joint, initial); M53.3 (Sacrococcygeal disorders)

- Diagnostics: X-ray pelvis (72170), MRI pelvis (72195), CT pelvis (72192)

- Treatments: SI joint injection (27096), SI joint radiofrequency ablation (64625), SI joint fusion (27279)

P. Sacroiliitis (NON-INJURY)

- ICD-10: M46.1 (Sacroiliitis, NEC)

- Diagnostics: MRI pelvis (72195), X-ray SI joints (72200), Lab work (HLA-B27, ESR, CRP)

- Treatments: SI joint injection (27096), Physical therapy (97110/97140)

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VI. UPPER EXTREMITY

Q. Rotator Cuff Tear (INJURY)

- ICD-10: M75.101/M75.102 (Unspecified rotator cuff tear, R/L); S46.011A (Strain of rotator cuff, R, initial)

- Diagnostics: MRI shoulder w/o contrast (73221), X-ray shoulder (73030), Ultrasound shoulder (76881)

- Treatments: Subacromial injection (20610), Rotator cuff repair open (23410/23412), Arthroscopic repair (29827)

R. Shoulder Impingement Syndrome (INJURY or NON-INJURY)

- ICD-10: M75.41/M75.42 (Impingement syndrome, R/L shoulder)

- Diagnostics: MRI shoulder (73221), X-ray shoulder (73030)

- Treatments: Subacromial bursa injection (20610), Arthroscopic subacromial decompression (29826), Physical therapy (97110)

S. Carpal Tunnel Syndrome (NON-INJURY or INJURY)

- ICD-10: G56.01/G56.02 (Carpal tunnel syndrome, R/L)

- Diagnostics: EMG/NCS (95860, 95907-95913), Ultrasound wrist (76882)

- Treatments: Carpal tunnel injection (20526), Carpal tunnel release (64721)

T. Cubital Tunnel Syndrome / Ulnar Neuropathy (INJURY or NON-INJURY)

- ICD-10: G56.21/G56.22 (Lesion of ulnar nerve, R/L)

- Diagnostics: EMG/NCS (95860, 95907-95913), MRI elbow (73221)

- Treatments: Ulnar nerve transposition (64718), Nerve block (64450)

U. Lateral Epicondylitis (INJURY or NON-INJURY)

- ICD-10: M77.11/M77.12 (Lateral epicondylitis, R/L elbow)

- Diagnostics: X-ray elbow (73070), MRI elbow (73221), Ultrasound elbow (76881)

- Treatments: Injection (20551), PRP injection (0232T), Physical therapy (97110)

V. Complex Regional Pain Syndrome – Upper Extremity (INJURY)

- ICD-10: G90.511/G90.512 (CRPS I, R/L upper limb); G56.41/G56.42 (Causalgia/CRPS II, R/L upper limb)

- Diagnostics: Triple-phase bone scan (78300), X-ray extremity (73120), EMG/NCS (95860)

- Treatments: Stellate ganglion block (64510), Spinal cord stimulator trial (63650), Spinal cord stimulator permanent (63685), Physical therapy (97110)

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VII. LOWER EXTREMITY

W. Knee Meniscus Tear (INJURY)

- ICD-10: M23.211/M23.212 (Derangement anterior horn medial meniscus, R/L); S83.211A (Bucket-handle tear medial meniscus, R, initial)

- Diagnostics: MRI knee w/o contrast (73721), X-ray knee (73560)

- Treatments: Knee joint injection (20611), Arthroscopic meniscectomy (29881), Arthroscopic meniscus repair (29882)

X. Knee Osteoarthritis (NON-INJURY or POST-TRAUMATIC)

- ICD-10: M17.11/M17.12 (Primary OA, R/L knee); M17.31/M17.32 (Post-traumatic OA, R/L knee)

- Diagnostics: X-ray knee (73560), MRI knee (73721)

- Treatments: Knee joint injection – corticosteroid (20611), Viscosupplementation (20611 + J7325), Genicular nerve block (64450), Genicular nerve RFA (64624), Total knee arthroplasty (27447)

Y. Peroneal Neuropathy / Sciatic Nerve Lesion (INJURY)

- ICD-10: G57.31/G57.32 (Lesion of lateral popliteal nerve, R/L); G57.01/G57.02 (Lesion of sciatic nerve, R/L)

- Diagnostics: EMG/NCS (95861, 95907-95913), MRI lower extremity (73718)

- Treatments: Nerve block (64450), Physical therapy (97110), Nerve decompression (64708)

Z. Plantar Fasciitis (NON-INJURY or INJURY)

- ICD-10: M72.2 (Plantar fascial fibromatosis); M77.31/M77.32 (Calcaneal spur, R/L)

- Diagnostics: X-ray foot (73630), Ultrasound foot (76882), MRI foot (73721)

- Treatments: Plantar fascia injection (20550), Physical therapy (97110), Extracorporeal shockwave therapy (0101T)

AA. Complex Regional Pain Syndrome – Lower Extremity (INJURY)

- ICD-10: G90.521/G90.522 (CRPS I, R/L lower limb); G57.71/G57.72 (Causalgia/CRPS II, R/L lower limb)

- Diagnostics: Triple-phase bone scan (78300), X-ray extremity (73590), EMG/NCS (95861)

- Treatments: Lumbar sympathetic block (64520), Spinal cord stimulator trial (63650), Spinal cord stimulator permanent (63685), Physical therapy (97110)

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VIII. CROSS-CUTTING PROCEDURES (ALL REGIONS)

Imaging Guidance (billed with injection procedures)

- Fluoroscopic guidance: 77003

- CT guidance: 77012

- Ultrasound guidance: 76942

Electrodiagnostic Studies

- Needle EMG: 95860 (1 extremity), 95861 (2 extremities), 95863 (3 extremities), 95864 (4 extremities)

- Nerve conduction studies: 95907–95913 (based on number of studies)

Neurostimulation (for refractory pain)

- SCS trial electrode placement: 63650

- SCS permanent implant pulse generator: 63685

- SCS revision/removal: 63661/63688

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IX. DOCUMENTATION CHECKLIST FOR MEDICAL NECESSITY

1. Specific diagnosis with highest-specificity ICD-10 code (laterality, level, encounter type)

2. Mechanism of injury (for injury-related: date, type, causation)

3. Symptom severity and functional impairment (use validated scales: VAS, ODI, NDI)

4. Failed conservative treatments with dates and duration (PT, medications, home exercise)

5. Objective findings: imaging results, EMG/NCS findings, physical exam

6. Clinical rationale linking diagnosis → diagnostic test or treatment

7. Prior authorization requirements met per payer-specific LCD/NCD

8. For repeat procedures: documented prior response (≥50% relief, duration of benefit)

FOOT AND ANKLE MRI ...

SCENARIO 1: MOTOR VEHICLE ACCIDENT (MVA)

Assessment:

Right foot and ankle pain status post MVA on [DATE]. Patient reports pain localized to both the midfoot and ankle with weight-bearing difficulty. Exam reveals tenderness over the midfoot/Lisfranc region AND lateral ankle with positive anterior drawer. Radiographs negative for fracture. Clinical suspicion for occult midfoot fracture/Lisfranc injury AND ankle ligamentous injury. These are anatomically distinct injuries requiring separate imaging fields of view.

Plan:

MRI right foot without contrast (CPT 73718) — evaluate for occult midfoot fracture, Lisfranc ligament disruption, plantar plate injury, and metatarsal stress injury
MRI right ankle without contrast (CPT 73721) — evaluate for ATFL/CFL tear, syndesmotic injury, osteochondral lesion of the talus, and peroneal tendon pathology
ICD-10: S99.911A (Unspecified injury of right foot, initial), S99.011A (Unspecified injury of right ankle, initial); add V43.52XA (Car passenger injured in collision, initial)

Medical Necessity Justification: Separate MRI studies are required because the foot and ankle are distinct anatomical regions with different coil positioning and field of view. A single ankle MRI does not adequately visualize the midfoot and forefoot structures (Lisfranc complex, metatarsals, plantar plate), and a foot MRI does not adequately evaluate the tibiotalar joint, syndesmosis, or lateral ankle ligaments. The mechanism of MVA can produce simultaneous but independent injuries to both regions.

SCENARIO 2: SLIP AND FALL

Assessment:

Left foot and ankle pain following slip and fall on [DATE]. Patient landed with forced inversion and plantar flexion. Exam demonstrates swelling and ecchymosis over the lateral ankle AND tenderness along the fifth metatarsal base and midfoot. Positive squeeze test. Radiographs equivocal. Clinical concern for lateral ankle ligament tear AND occult fifth metatarsal (Jones) fracture. Distinct anatomic injury patterns warrant separate imaging.

Plan:

MRI left foot without contrast (CPT 73718) — evaluate for occult fifth metatarsal fracture, cuboid fracture, midfoot ligamentous injury, and plantar fascia pathology
MRI left ankle without contrast (CPT 73721) — evaluate for lateral ligament complex tear (ATFL/CFL), peroneal tendon subluxation/tear, osteochondral defect, and bone marrow edema
ICD-10: S93.402A (Sprain of unspecified ligament of left ankle, initial), S99.912A (Unspecified injury of left foot, initial); add W01.0XXA (Fall on same level from slipping, initial)

Medical Necessity Justification: The slip-and-fall mechanism produces distinct injury patterns in the ankle (ligamentous/osteochondral) and foot (osseous/midfoot). The MRI ankle coil and field of view are centered on the tibiotalar joint and cannot adequately image the metatarsals, cuboid, or plantar structures. Conversely, the foot MRI field of view does not capture the ankle mortise or syndesmosis. Both studies are necessary to fully characterize the extent of injury and guide treatment.

SCENARIO 3: WORK-RELATED INJURY

Assessment:

Right foot and ankle pain sustained during occupational injury on [DATE] (e.g., heavy object dropped on foot / fall from height at worksite). Patient reports pain in both the ankle joint and across the dorsal midfoot/forefoot. Exam reveals ankle joint effusion, limited dorsiflexion, AND midfoot swelling with pain on passive abduction of the forefoot. Radiographs inconclusive. Clinical concern for ankle osteochondral injury AND Lisfranc/midfoot fracture-dislocation. Two anatomically separate injury zones identified on exam.

Plan:

MRI right foot without contrast (CPT 73718) — evaluate for Lisfranc ligament disruption, midfoot/metatarsal fracture, plantar plate tear, and soft tissue injury
MRI right ankle without contrast (CPT 73721) — evaluate for osteochondral lesion of the talus, tibiotalar effusion, tendon injury (posterior tibial, Achilles), and syndesmotic disruption
ICD-10: S99.911A (Unspecified injury of right foot, initial), S99.011A (Unspecified injury of right ankle, initial); add Y93.89 (Activity, other specified) and Y99.0 (Civilian activity done for income or pay)

Medical Necessity Justification: Workers' compensation cases require thorough documentation of all injuries. The foot and ankle represent separate anatomic compartments with distinct pathology requiring different MRI coil placement, slice orientation, and field of view. A single MRI cannot simultaneously optimize visualization of both the ankle joint complex and the midfoot/forefoot structures. Ordering both studies at the same encounter is clinically efficient, avoids delayed diagnosis, and supports timely return-to-work planning.

ACR Appropriateness Criteria® Chronic Foot Pain: Update 2025.

Journal of the American College of Radiology : JACR. 2026. Expert Panel on Musculoskeletal Imaging, Said N, Fox MG, et al.RecentGuideline

ACR Appropriateness Criteria® Acute Trauma to the Ankle.

Journal of the American College of Radiology : JACR. 2020. Smith SE, Chang EY, Ha AS, et al.Guideline

ACR Appropriateness Criteria® Chronic Foot Pain.

Journal of the American College of Radiology : JACR. 2020. Tafur M, Bencardino JT, Roberts CC, et al.Guideline

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