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ICD-10-CM L90.2, Anetoderma of Jadassohn-Pellizzari | No Prior Auth

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`L90.2`, Anetoderma of Jadassohn-Pellizzari

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical records must document the indication(s) supporting use of IVIG for each claim.
For indications where routine IVIG use is not indicated, the medical record must document prior interventions that were unsuccessful or reasons those interventions were not tolerated.
Documentation must support objective clinical response to IVIG for continued coverage.
Medical records must be made available to the Contractor upon request to substantiate coverage and payment.

Key Coverage Criteria

IVIG is covered only for indications specified as covered in the related Local Coverage Determination (LCD) and when medical necessity criteria in that LCD are met.
(Inferred from references) Iontophoresis for treatment of rheumatoid arthritic knees
(Inferred from references) Transepithelial iontophoresis corneal collagen cross-linking for progressive keratoconus
(Inferred from references) Whole-finger iontophoresis to increase blood flow in systemic sclerosis
(Inferred from references) Transdermal iontophoretic drug delivery platforms/technologies (general)
(Inferred from references) Conservative treatments, including iontophoresis, for patellar tendinopathy

4 Active Policies

WPS-J5-L34771, Immune Globulins

J5

A57554, Billing and Coding: Immune Globulins

J5

WPS-J8-L34771, Immune Globulins

J8

AETNA-CPB-0229, Iontophoresis

Related Codes

90371(3 policies)90375(3 policies)90376(3 policies)90393(3 policies)90396(3 policies)96365(3 policies)96366(3 policies)96372(3 policies)

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For any iontophoretic dermatologic or ophthalmologic application: documentation of agent(s) used, concentrations, device/model, current and duration parameters, and monitoring for local adverse effects (erythema, burns, corneal complications, etc.).

No documentation requirements are stated in this document chunk (bibliography).