Does B97.4 require prior authorization?

No, B97.4 does not require prior authorization (high confidence). Covered without prior authorization.

`B97.4`, Respiratory syncytial virus as the cause of diseases classified elsewhere

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Evidence of blood levels demonstrating significant gammaglobulin deficiency prior to initial treatment should be documented where appropriate.
Medical record must document medical necessity to initiate and continue IVIG, including history and physical and office/progress notes.
Test results with written interpretation must be in the record, including relevant diagnostic testing (e.g., NCS, EMG, CSF, serum immunoprotein, muscle/nerve biopsy) as appropriate to the treated condition.
Accurate weight in kilograms must be documented prior to each infusion since IVIG dosing is mg/kg.

Off-label IVIG use may be billed when supported by the applicable Local Coverage Determination (LCD) and by documentation of medical necessity; off-label is defined as not in Medicare-approved compendia or the FDA label.
IVIG may be used in bone marrow/stem cell transplantation when the recipient was CMV seropositive before transplantation, or after allogeneic transplantation for hematologic neoplasm when both donor and recipient were CMV seronegative.
IVIG may be used in solid organ transplantation when the donor was CMV seropositive and the recipient was CMV seronegative prior to transplantation.
IVIG may be used for recurrent severe infections when there is documented severe or absent IgG subclass deficiency or clinically significant functional humoral immunity deficiency (failure to produce specific antibodies) with a history of recurrent infections.
IVIG may be used for neuromuscular disorders when objective improvement is demonstrated and continued treatment is required, provided quantitative assessments are documented to monitor progress.
Use of IVIG for autoimmune mucocutaneous blistering disease should follow CMS National Coverage Determination (Medicare NCD Chapter 1, Section 250.3).

NGS-J6-L39314, Off-Label Use of Intravenous Immune Globulin (IVIG)

A59105, Billing and Coding: Off-Label Use of Intravenous Immune Globulin (IVIG)

NGS-JK-L39314, Off-Label Use of Intravenous Immune Globulin (IVIG)

AETNA-CPB-0155, Ribavirin for Inhalation Use

AETNA-CPB-0318

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