Does L13.1 require prior authorization?

No, L13.1 does not require prior authorization (high confidence). Covered without prior authorization.

`L13.1`, Subcorneal pustular dermatitis

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

The medical record must include the assessment by the ordering provider as it relates to the patient's complaint for that visit.
Document relevant medical history, results of pertinent tests/procedures, and signed and dated office visit records or operative reports.
Document previous treatments including medication(s), dosing, frequency, duration of treatment(s), and documentation of response(s).
If use is due to lack of efficacy, include documentation of prior treatment(s) with dosing, frequency, duration, and response(s).

Off-label use of rituximab or rituximab biosimilars is allowable when the patient has documented lack of efficacy of prior treatments, including dosing, frequency, duration, and documentation of response(s).
Off-label use is allowable when first-line therapy produced an adverse reaction that absolutely contraindicates further use or causes non-transient side effects that impair functional capacity or activities of daily living, with the adverse event documented.
Off-label use is allowable for refractory disease when documentation includes all first-line treatment(s) with dosing, frequency, duration, and documentation of response(s).
Off-label use is allowable for disease relapse when documentation includes prior first-line treatment(s) with dosing, frequency, duration, duration of improvement on prior treatment(s), pertinent clinical history, exam findings, test results supporting relapse, and documentation of response to treatment at time of relapse.
Re-treatment with rituximab or a biosimilar after initial treatment is permitted only when a positive response to prior rituximab is documented in the medical record.
Patients treated with rituximab are expected to receive standard dosing regimens consistent with medical literature for the treated condition.

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

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

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

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