Does M05.A require prior authorization?

No, M05.A does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`M05.A`, Abnormal rheumatoid factor and anti-citrullinated protein antibody with rheumatoid arthritis

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

Refer to Local Coverage Determination L35026 for clinical coverage criteria, medical necessity requirements, and any required prior authorization; this article complements that LCD with billing/coding guidance.
Providers must follow the Local Coverage Determination (LCD) L35677 for clinical indications, coverage decisions, and documentation requirements for infliximab.
The article provides billing and coding guidance and references LCD L39116; required documentation (e.g., medical records, prior authorization, specific forms) is not specified here and must be obtained from LCD L39116.

This billing and coding article references Local Coverage Determination LCD L39624 for coverage and documentation requirements for amniotic and placental-derived product injections/applications for musculoskeletal (non-wound) indications; the LCD text was not provided so specific documentation requirements cannot be extracted.

Key Coverage Criteria

No specific clinical indications are provided in this billing and coding article; coverage criteria for amniotic and placental-derived product injections/applications for musculoskeletal non-wound indications are described in Local Coverage Determination L39116.
Coverage applies when the amniotic or placental-derived product injection/application meets the reasonable and necessary requirements of Local Coverage Determination L39877.
Amniotic and placental-derived product injections/applications are covered only when they meet the reasonable and necessary clinical requirements specified in LCD L39879 (Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound).
Fundus photography is consideredmedically necessaryto document abnormalities or disease processes (not screening) affecting the eye or to follow the progress of such eye disease when the results of fundus photography will be used to direct therapy and improve clinical outcomes. [...]
Diabetic retinopathy
To further evaluate or monitor glaucoma or glaucoma suspects

9 Active Policies

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

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

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

A56432, Billing and Coding: Infliximab

ANTHEM-CG-MED-47, Fundus Photography

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

ANTHEM-MP-A053844, TRANS.00031 Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors

A56380, Billing and Coding: Rituximab

`M05.A`, Abnormal rheumatoid factor and anti-citrullinated protein antibody with rheumatoid arthritis

Prior Authorization

Documentation Required

Key Coverage Criteria

9 Active Policies

Related Codes

Have a follow-up question?

M05.A, Abnormal rheumatoid factor and anti-citrullinated protein antibody with rheumatoid arthritis

Prior Authorization

Documentation Required

Key Coverage Criteria

9 Active Policies

Related Codes

Have a follow-up question?

`M05.A`, Abnormal rheumatoid factor and anti-citrullinated protein antibody with rheumatoid arthritis