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ICD-10-CM M05.152, Rheumatoid lung disease with rheumatoid arthritis of left hip | No Prior Auth

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`M05.152`, Rheumatoid lung disease with rheumatoid arthritis of left hip

ICD-10-CM

Prior Authorization

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Documentation Required

Medical records must document the basis for each diagnosis and that diagnoses follow recognized standards (eg, American College of Rheumatology guidelines).
Medical records must include patient weight when needed to determine appropriate dosing.
Medical records must document evaluation for latent tuberculosis infection with a medical evaluation and TB test, and initiation of latent TB treatment prior to infliximab when indicated.

Medical records must document disease‑specific relevant symptoms and signs that are being treated and monitored to assess response to treatment.

For biologic initiation, documentation must show inadequate response (lack of efficacy, adverse effects, or contraindication) to a 3‑month trial of appropriately dosed, disease‑specific conventional (non‑biologic) therapy.

For plaque psoriasis, documentation should include percent body surface area affected, PASI score, PDI score, or other psoriasis assessment tools and documentation of planned close follow‑up; monitor for nonmelanoma skin cancer especially after prior prolonged phototherapy.

Key Coverage Criteria

Infliximab and its FDA‑approved biosimilars are covered when administered in accordance with the FDA‑approved label or recognized compendia for labeled and off‑label uses.
Covered for Crohn's disease when medical records document disease‑specific signs/symptoms (eg, abdominal pain, diarrhea, fistulae) and dosing per label or compendia; retreatment is covered if prior initial treatment produced reduction in clinical signs and symptoms.
Covered for rheumatoid arthritis when prescribed per label/compendia and medical record documents concomitant methotrexate use or a documented contraindication to methotrexate.
Covered for plaque psoriasis when documentation shows chronic, severe, extensive, or disabling disease (eg, percent BSA, PASI, or PDI) and the patient will have close physician follow‑up and monitoring.
Claims for pyoderma gangrenosum with coexisting inflammatory bowel disease are covered when the claim includes both primary and secondary ICD‑10‑CM diagnosis codes documenting pyoderma gangrenosum and IBD.
Coverage determinations for biomarker testing follow Local Coverage Determination L35062 and services are covered when reasonable and necessary per that LCD.

20 Active Policies

CGS-J15-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J15

CGS-J18-L34399, Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J18

A59434, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J5

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

J6

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

J6

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J6

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

J6

A52423, Billing and Coding: Infliximab and biosimilars

J6

A59764, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J9

FIRST_COAST-L34021, Sedimentation Rate, Erythrocyte

J9

A57657, Billing and Coding: Sedimentation Rate, Erythrocyte

J9

NOVITAS-JH-L39063, Pharmacogenomics Testing

JH

NOVITAS-JH-L35062, Biomarkers Overview

JH

NGS-JK-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

JK

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

JK

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

JL

NOVITAS-JL-L35062, Biomarkers Overview

JL

NOVITAS-JL-L39063, Pharmacogenomics Testing

JL

A56541, Billing and Coding: Biomarkers Overview

JL

A56580, Billing and Coding: Computerized Axial Tomography (CT), Thorax

Related Codes

M05.122(20 policies)M05.141(20 policies)M05.112(20 policies)M05.121(20 policies)M05.131(20 policies)M05.132(20 policies)M05.111(20 policies)M05.142(20 policies)

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