Does M06.369 require prior authorization?

No, M06.369 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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`M06.369`, Rheumatoid nodule, unspecified knee

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

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.

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.
Scanning computerized ophthalmic diagnostic imaging (SCODI) is covered when the service meets the medical necessity criteria and is included within Local Coverage Determination L34380.

20 Active Policies

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

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

NGS-J6-L34380, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)

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

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M06.369, Rheumatoid nodule, unspecified knee