Does L12.8 require prior authorization?

No, L12.8 does not require prior authorization (high confidence). Code is covered without prior authorization.

`L12.8`, Other pemphigoid

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation should demonstrate the presence of at least one qualifying indication (e.g., records documenting failure of conventional therapy, documentation of contraindication, or evidence of rapidly progressive disease and rationale for short-term IVIg use with conventional therapy).
Be aware that local contractors may require additional local documentation or definitions (e.g., local coverage determination/criteria), and providers should follow Noridian or applicable LCD requirements.
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.

IVIg is covered when the patient has failed conventional therapy for the treated condition.
IVIg is covered when conventional therapy is contraindicated for the patient.
IVIg is covered for rapidly progressive disease when a clinical response cannot be achieved quickly enough using conventional agents and IVIg is used only short-term alongside conventional treatment until that therapy takes effect.
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.
Billing and coding guidance in this article applies when immune globulin use meets the reasonable and necessary coverage criteria established in LCD L35093.

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

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