Does L50.9 require prior authorization?

No, L50.9 does not require prior authorization (high confidence). Covered without prior authorization.

`L50.9`, Urticaria, unspecified

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Medical records must document the clinical indication and justification for omalizumab, including pre-treatment symptoms and objective spirometry (FEV1 and FEV1/FVC) consistent with moderate or severe persistent asthma when used for asthma.
Claims must document that administration occurred in a clinic or office by a physician or incident-to a physician and include evidence of post-administration observation and readiness to manage anaphylaxis.
Dose and frequency used must be supported by the FDA label or a recognized compendium citation in the medical record for covered uses or off-label compendia-supported uses.
The patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Omalizumab is covered when administered by a physician or incident-to a physician’s service in a clinic or office setting.
Dose and frequency of omalizumab must follow the FDA-approved label or recognized compendia for the indicated or off-label use.
Use for patients with moderate or severe persistent asthma as defined by NHLBI clinical features and pre-treatment spirometry (FEV1 and FEV1/FVC thresholds by age) is the clinical context described in the policy.
Patients should receive omalizumab in a healthcare setting and be observed for an appropriate period after each treatment; administration must be by providers prepared to recognize and manage anaphylaxis.
RAST type tests are covered when medically necessary and supported by the related Local Coverage Determination (LCD) and current medical literature or standards of practice.
Excision of a benign skin lesion is covered when there is clinical suspicion of malignancy (e.g., ICD-10-CM D48.5) documented in the medical record.

CGS-J15-L34200, Removal of Benign Skin Lesions

J15

CGS-J18-L34200, Removal of Benign Skin Lesions

J18

NGS-J6-L33591, RAST Type Tests

A52448, Billing and Coding: Omalizumab and biosimilar, OMLYCLO (omalizumab-igec)

A56844

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