Does B17.11 require prior authorization?

No, B17.11 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

Backwork Sign up free

`B17.11`, Acute hepatitis C with hepatic coma

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

This billing and coding article provides guidelines that complement Local Coverage Determination L34415 for CT of the abdomen and pelvis; consult LCD L34415 for specific coverage indications, limitations, and documentation requirements.
Providers must maintain patient weight in kilograms, ESA units administered per kilogram, and medical justification for any ESA doses exceeding usual doses.
The medical record must include the ordering provider's assessment related to the visit complaint, relevant medical history, results of pertinent tests/procedures, and a signed and dated office visit record or operative report.
For all patients receiving ESAs the medical record must document hemoglobin (Hgb) or hematocrit (Hct) and evidence of adequate iron stores.

Key Coverage Criteria

Administration of erythropoiesis stimulating agents (ESAs) billed with HCPCS J0881, J0882, J0885, J0886, Q4081, Q5105, or Q5106 for patients with anemia related to ESRD, chronic kidney disease (CKD), chemotherapy, radiation, or myelodysplastic syndrome (MDS), when the use meets the coverage criteria in the applicable LCD.
Use of ESAs for chemotherapy-induced, radiation-induced, or non-chemo/non-radiation anemia should be identified on non-ESRD claims by reporting modifier EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio).
ESA administration may qualify as a Home Health service only when the beneficiary is receiving the ESA for a covered indication specified in the LCD.
ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.

15 Active Policies

CGS-J15-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L40386, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J18-L40386, Erythropoiesis Stimulating Agents (ESA)

J18

CGS-J18-L34356, Erythropoiesis Stimulating Agents (ESA)

J18

A56795

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about B17.11 Sign up free

B17.11, Acute hepatitis C with hepatic coma