Does D89.1 require prior authorization?

No, D89.1 does not require prior authorization (high confidence). Covered without prior authorization.

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`D89.1`, Cryoglobulinemia

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Claims must include the appropriate CPT® or PLA code; if no proprietary CPT/PLA code exists, bill with the appropriate CPT® code or CPT® 87999 if no other CPT describes the service.
Tests billed with CPT® 87999 or tests without a proprietary CPT/PLA code require submission of a DEX Z-code identifier and a MolDX Technical Assessment (TA).
Enter the appropriate DEX Z-code adjacent to the CPT® code in the specified claim fields: Part B — Loop 2400 or SV101-7 (837P) and Box 19 (paper); Part A — Line SV202-7 (837I) and Block 80 (UB04).
ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim and the chosen diagnosis must be documented in the beneficiary’s medical record.

Key Coverage Criteria

Molecular syndromic infectious disease panels are covered when billed with the appropriate proprietary CPT® or PLA code and an accompanying ICD-10-CM diagnosis that documents medical necessity in the patient record.
FDA-cleared/approved molecular infectious disease tests performed consistent with their intended use are covered without a DEX Z-code when billed with an appropriate supporting ICD-10-CM code.
A panel is a single test (single unit of service UOS=1) and is covered as one service even if it reports multiple pathogens or targets.
Testing for additional organisms not included in a billed panel is covered when ordered in addition to the panel and supported by documentation in the medical record.
Expanded (>5 pathogen) respiratory (RP/PNP) and gastrointestinal (GI) panels are covered when either (a) performed at POS 19, 21, 22, or 23, or (b) ordered by an approved specialist per patient immune status and clinical indication (see documentation criteria).
Pre-transplant evaluation panels for immune-compromised beneficiaries are covered regardless of symptoms when clear pre-transplant documentation accompanies the claim.

20 Active Policies

CGS-J15-L34037, Flow Cytometry

J15

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

J15

CGS-J18-L34037, Flow Cytometry

J18

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

J18

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Modifier 59 must be appended when reporting different species or strains reported by the same code and must be used as an attestation when multiple distinct procedural services are performed on the same date of service.

For expanded (>5 pathogen) RP/PNP/GI panels performed outside POS 19/21/22/23, the ordering provider specialty and the beneficiary immune status must be documented as follows: immune-competent — ordered by Infectious Disease specialist or Pulmonologist (RP/PNP) or Gastroenterologist (GI); immune-compromised — ordered by specialist in Infectious Diseases, Oncology, Transplant (any panel), Pulmonologist (RP/PNP) or Gastroenterologist (GI).

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

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

A59101, Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars

NGS-J6-L39226, Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)

NGS-J6-L39297, Off-label Use of Rituximab and Rituximab Biosimilars

A58963, Billing and Coding: Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)

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

FIRST_COAST-L38227, Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)

FIRST_COAST-L38918, Respiratory Pathogen Panel Testing

NOVITAS-JH-L38229, Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)

NOVITAS-JH-L38916, Respiratory Pathogen Panel Testing

NGS-JK-L39226, Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE)

NGS-JK-L39297, Off-label Use of Rituximab and Rituximab Biosimilars

NGS-L39027, Respiratory Pathogen Panel Testing

NOVITAS-JL-L38916, Respiratory Pathogen Panel Testing

NOVITAS-JL-L38229, Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs)

D89.1, Cryoglobulinemia