Does D46.1 require prior authorization?

No, D46.1 does not require prior authorization (high confidence). Code is covered without prior authorization.

`D46.1`, Refractory anemia with ring sideroblasts

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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).

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.
Use CPT codes 88271-88291 when in situ hybridization (ISH) is performed as an ancillary analysis to cytogenetic studies for oncologic or inherited disorders.
Use CPT codes 88365-88377 when a pathologist performs ISH techniques as an adjunct to a surgical pathology or cytopathology case (distinguishes qualitative vs quantitative analysis).
Bill this policy's procedures when submitting claims for Next-Generation Sequencing (NGS) lab-developed tests (LDTs) for myeloid malignancies or suspected myeloid malignancies.

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

J15

CGS-J15-L38070, MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

J15

CGS-J15-L34037, Flow Cytometry

J15

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

J15

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