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ICD-10-CM L44.0, Pityriasis rubra pilaris | No Prior Auth

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`L44.0`, Pityriasis rubra pilaris

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For transplant rejection and GVHD indications: documentation that disease is refractory to standard immunosuppressive drug treatment (clear record of prior and/or concurrent standard therapies, doses, dates, and documented lack of adequate response or contraindication to standard therapy).
For GVHD after allogeneic bone marrow/stem cell transplant: documentation that disease is refractory to standard immunosuppressive drug treatment.
Documentation of transplant status (e.g., appropriate Z94.xx codes) where relevant.
No explicit 'Documentation Requirements' section appears in the provided text. Inferred documentation to support medical necessity based on the policy text includes:

Key Coverage Criteria

ICD-10 codes covered if selection criteria are met (as listed in the policy):
C84.00 - C84.09: Mycosis fungoides
C84.10 - C84.19: Sezary's disease
C84.A0 - C84.A9: Cutaneous T-cell lymphoma, unspecified
D89.810 - D89.813: Graft-versus-host disease
J42: Unspecified chronic bronchitis [only covered for rejection (bronchiolitis obliterans) in lung transplants] [not covered for bronchiolitis obliterans syndrome after allogeneic stem cell transplantation]

1 Active Policy

AETNA-CPB-0241, Extracorporeal Photochemotherapy (Photopheresis)

Related Codes

B12(1 policies)C84.(1 policies)C84.00(1 policies)C84.09(1 policies)C84.10(1 policies)C84.19(1 policies)D51.0(1 policies)36522(1 policies)

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For cutaneous T‑cell lymphoma: documentation of diagnosis and stage (e.g., mycosis fungoides, Sézary's syndrome; stage III erythrodermic disease when claiming FDA‑standard indication).

For bronchiolitis obliterans syndrome (BOS) or chronic lung allograft dysfunction: baseline and serial pulmonary function tests (including FEV1 and FEV1 % predicted) demonstrating decline consistent with BOS, and documentation of enrollment in a CMS‑approved clinical research study when coverage is sought under the NCD (e.g., study identifier and evidence of meeting CED requirements).