Does L10.89 require prior authorization?

No, L10.89 does not require prior authorization (high confidence). Code is covered without prior authorization.

Backwork Sign up free

`L10.89`, Other pemphigus

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.
Billing must comply with Medicare rules and any applicable LCD prior authorization or documentation requirements; follow any specific forms or prior authorization processes required by the LCD or payer.
The medical record must include the ordering provider's assessment related to the complaint, relevant medical history, results of pertinent tests/procedures, and signed and dated office visit or operative reports.
Required documentation of medical necessity includes history and physical, a supporting physician rationale current within the last 12 months, and physician orders not more than 30 days old specifying dose, frequency, administration route and duration, with office/progress notes documenting necessity for initiation and continuation.

Key Coverage Criteria

Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
IVIG is covered for patients with common variable immunodeficiency (CVID) when initial presenting IgG levels, evidence of Pneumovax vaccination, and pre- and post-vaccine pneumococcal antibody titers demonstrate inability to produce an antibody response to protein or carbohydrate antigens, and documentation includes dual diagnoses and a statement of lack of response to protein antigen.
IVIG is covered for patients with HIV disease and immune thrombocytopenic purpura (ITP) when the medical record documents a platelet count less than 30,000 and active bleeding supported by laboratory results.
IVIG is covered for immunodeficient individuals with recurrent or chronic bacterial sinusitis when the record documents findings diagnostic of or highly suggestive of bacterial sinus infection (for example fever, unilateral purulent nasal discharge, unilateral facial pain) and documents prolonged and/or recurrent antibiotic therapy.
IVIG is covered for stiff-man syndrome when the patient is under the care of a physician competent in diagnosis, meets the defined diagnostic criteria, has failed conservative therapy (e.g., benzodiazepines), and documentation shows objective response after initial treatment for continued coverage.

20 Active Policies

CGS-J15-L35891, Intravenous Immune Globulin

J15

CGS-J18-L35891, Intravenous Immune Globulin

J18

A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

WPS-J5-L34771, Immune Globulins

WPS-J5-L37205

Have a follow-up question?

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

Ask Backwork about L10.89 Sign up free

L10.89, Other pemphigus