Does D75.81 require prior authorization?

No, D75.81 does not require prior authorization (high confidence). Covered without prior authorization.

Backwork Sign up free

`D75.81`, Myelofibrosis

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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

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.
Non-invasive peripheral venous and hemodialysis access studies are covered when the results will be used to guide the clinical management of the patient.
Duplex scanning and physiologic studies may be performed and reimbursed during the same encounter when physiologic studies are abnormal or when evaluating vascular trauma, thromboembolic events, or aneurysmal disease.
One preoperative scan for hemodialysis access site surgery is covered to plan access creation.

20 Active Policies

CGS-J15-L38822, MolDX: Minimal Residual Disease Testing for Cancer

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-L40000, MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

J15

Have a follow-up question?

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

Ask Backwork about D75.81 Sign up free

Claims must report the most recent Hb or Hct reading on the claim: institutional claims use value code 48 (Hb) or 49 (HCT); professional paper claims place results in item 19 of CMS-1500; electronic 837P claims use Loop 2400 MEA with MEA01=TR, MEA02=R1 (Hb) or R2 (HCT), and MEA03=the test result.

The referring physician/nonphysician practitioner must state the clinical indication/medical necessity in the order for the test and provide the order to the performing provider.

CGS-J18-L40000, MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

J18

CGS-J18-L38070, MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

J18

CGS-J18-L38822, MolDX: Minimal Residual Disease Testing for Cancer

J18

CGS-J18-L34037, Flow Cytometry

J18

A58756, Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

A57594, Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

A59004, Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers

WPS-J5-L40022, MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

WPS-J5-L38176, MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

A57878, Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies

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

WPS-J5-L38835, MolDX: Minimal Residual Disease Testing for Cancer

WPS-J5-L39040, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

WPS-J5-L35751, Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies

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

A59939, Billing and Coding: MolDX: Non-Next Generation Sequencing Tests for the Diagnosis of BCR-ABL Negative Myeloproliferative Neoplasms

D75.81, Myelofibrosis