Does B27.00 require prior authorization?

No, B27.00 does not require prior authorization (high confidence). Covered without prior authorization.

`B27.00`, Gammaherpesviral mononucleosis without complication

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.
Billing must comply with Medicare rules and any applicable LCD prior authorization or documentation requirements; follow any specific forms or prior authorization processes required by the LCD or payer.
Refer to Local Coverage Determination L35026 for clinical coverage criteria, medical necessity requirements, and any required prior authorization; this article complements that LCD with billing/coding guidance.
Medical record must document the specific ICD-10 diagnosis being treated and link the diagnosis to an accepted compendia listing or FDA-approved indication for the drug.

Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
Tonsillectomy is consideredmedically necessaryfor individuals 18 years of age and older who meet one or more of the criteria below:
A history of recurrent acute throat infection with a frequency of at least:Three or more episodes in the previous 6 months;orFour or more episodes in the previous 12 months;andDocumentation in the medical record for each episode of sore throat which includes at least one of the following:Temperature greater than 38.3 Â°C (100.9 Â°F);orCervical adenopathy;orTonsillar exudate or erythema;orPositive test for Group A Ã-hemolytic streptococcus (GABHS);or
Three or more episodes in the previous 6 months;or
Four or more episodes in the previous 12 months;and

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

WPS-J8-L37205, Chemotherapy Drugs and their Adjuncts

ANTHEM-CG-SURG-113, Tonsillectomy with or without Adenoidectomy for Adults

A56380

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