Does D63.8 require prior authorization?

No, D63.8 does not require prior authorization (high confidence). Covered without prior authorization.

`D63.8`, Anemia in other chronic diseases classified elsewhere

ICD-10-CM

No Prior Auth Required

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.
MolDX blood product molecular antigen typing panels 0001U and 0084U (germline tests) are covered for beneficiaries but are limited to one test per beneficiary lifetime.
Erythrocyte sedimentation rate (ESR) testing is covered only when reasonable and necessary as defined by Local Coverage Determination L34021.
ESR performed for rheumatoid arthritis patients to assess the need for medication adjustments should be billed with a diagnosis code that reflects the specific antirheumatic medication the patient is receiving.

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

J15

CGS-J15-L38249, MolDX: Blood Product Molecular Antigen Typing

J15

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

J15

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

J18

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