Does A68.9 require prior authorization?

No, A68.9 does not require prior authorization (high confidence). Covered without prior authorization.

`A68.9`, Relapsing fever, unspecified

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation of patient age to confirm adult status (≥18 years).
Clinical documentation that the member initiated a biologic or targeted synthetic DMARD for RA and is unresponsive/refractory or intolerant despite therapeutic dosing.
Documentation confirming no prior molecular biomarker testing for predictive therapy selection for rheumatoid arthritis.
Clinical or radiographic documentation supporting the diagnosis or suspicion of axial spondyloarthritis when ordering HLA-B27 typing.

Genetic testing for inherited immunodeficiency disorders
Molecular biomarker testing to predict response or non-response to medications for rheumatoid arthritis and related autoimmune disorders
Multigene panels for suspected Periodic Fever Syndromes (e.g., tests such as Invitae or PreventionGenetics) for members with clinical features consistent with periodic fever (ICD-10: M04.1, R50.9, A68.9).
Rheumatoid arthritis biomarker activity panels (e.g., Vectra) for assessment of disease activity in members with diagnosed rheumatoid arthritis (ICD-10: M05.00-M06.9).
TNF inhibitor (TNFi) treatment response algorithmic tests (e.g., PrismRA) to inform expected response to TNFi therapy in members with rheumatoid arthritis (ICD-10: M05, M06, M08).
HLA-B27 DNA typing for evaluation of axial spondyloarthritis or related seronegative spondyloarthropathies (ICD-10: M45 and related codes such as M04.8, M04.9, M05, M06).

AMBETTER-CG-Immune.Auto.RA.DO-2025.1, Concert Genetic Testing: Immune, Autoimmune, and Rheumatoid Disorders

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