Does L12.9 require prior authorization?

No, L12.9 does not require prior authorization (high confidence). Covered without prior authorization.

`L12.9`, Pemphigoid, 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.
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.

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.
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 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.

A57554, Billing and Coding: Immune Globulins

WPS-J5-L34771, Immune Globulins

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

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

A59101

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