Does L10.9 require prior authorization?

No, L10.9 does not require prior authorization (high confidence). Covered without prior authorization.

`L10.9`, Pemphigus, unspecified

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical records must document failure of conventional therapy, contraindication to conventional therapy, or presence of rapidly progressive disease to justify IVIg use.
When IVIg is used as a short-term adjunct while awaiting effect of conventional therapy, documentation must show concurrent conventional treatment and rationale for temporary IVIg use.
Refer to Local Coverage Determination L35026 for clinical coverage criteria, medical necessity requirements, and any required prior authorization; this article complements that LCD with billing/coding guidance.
Claims should reference and be supported by LCD L34580 and follow the billing/coding guidelines in this article; specific documentation requirements (e.g., medical records, prior authorization) are those detailed in LCD L34580.

Patient has failed conventional therapy.
Conventional therapy is contraindicated for the patient.
Patient has rapidly progressive disease in which a clinical response could not be achieved quickly enough with conventional agents; IVIg may be given along with conventional treatments and used only until conventional therapy takes effect.
Billing and coding for intravenous immunoglobulin (IVIG) should follow the Local Coverage Determination (LCD) L34580 and the billing/coding guidelines in this article as a complement to that LCD.
Billing and coding guidance in this article applies when immune globulin use meets the reasonable and necessary coverage criteria established in LCD L35093.
IVIG is covered only for indications specified as covered in the related Local Coverage Determination (LCD) and when medical necessity criteria in that LCD are met.

A57554, Billing and Coding: Immune Globulins

WPS-J5-L34771, Immune Globulins

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

NGS-J6-L39314, Off-Label Use of Intravenous Immune Globulin (IVIG)

A59101

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