Does B97.35 require prior authorization?

No, B97.35 does not require prior authorization (high confidence). Covered without prior authorization.

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`B97.35`, Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Claims must report the appropriate CPT code for the flow cytometry service, include 1 unit of service (UOS), and list the appropriate ICD-10-CM diagnosis code.
Medical necessity documentation per LCD L34513 is required when coverage criteria are not fully met in this billing guideline (for example, when >24 markers are requested).
Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.

Medical record must include most recent blood pressure and demonstrate reasonable control, weight in kilograms, date and results of Hb or HCT prior to ESA administration, and assessment that other causes of anemia are ruled out or managed.

Every page of the medical record must be legible with patient identification, dates of service, and the legible signature of the responsible physician or non-physician practitioner; submitted records must support the selected ICD-10-CM and CPT/HCPCS codes.

Non-ESRD claims for J0881, J0885 and Q5106 must include one of modifiers EA (chemo-induced), EB (radio-induced), or EC (non-chemo/radio); all applicable ESA claims must report exactly one route modifier: JA (IV), JB (subcutaneous), or JE (via dialysate).

Key Coverage Criteria

Coverage and medical necessity determinations for flow cytometry are governed by Local Coverage Determination L34513.
Flow cytometry may be used to analyze cellular components of body fluids and lymphoreticular tissues, including peripheral blood, cerebrospinal fluid (CSF), bone marrow, lymph nodes, tonsil, spleen, and fine needle aspirate material.
Peripheral blood or fine needle aspirate specimens may be used to avoid more invasive diagnostic procedures when clinically appropriate.
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.

20 Active Policies

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

J15

CGS-J15-L34037, Flow Cytometry

J15

CGS-J15-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J15

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

J15

CGS-J18-L34037, Flow Cytometry

J18

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

J18

CGS-J18-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J18

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

J18

A58761, Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

A56795, Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)

WPS-J5-L34633, Erythropoiesis Stimulating Agents (ESAs)

WPS-J5-L39044, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

NGS-J6-L40334, Erythropoiesis Stimulating Agents

NGS-J6-L40333, Erythropoiesis Stimulating Agents

WPS-J8-L34633, Erythropoiesis Stimulating Agents (ESAs)

WPS-J8-L39044, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

NGS-JK-L40333, Erythropoiesis Stimulating Agents

NGS-JK-L40334, Erythropoiesis Stimulating Agents

AETNA-CPB-0675, Bortezomib Products

A55717, Billing and Coding: Lab: Flow Cytometry

`B97.35`, Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

B97.35, Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`B97.35`, Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere