Does M06.811 require prior authorization?

No, M06.811 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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`M06.811`, Other specified rheumatoid arthritis, right shoulder

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

Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.
Billing must comply with Medicare rules and any applicable LCD prior authorization or documentation requirements; follow any specific forms or prior authorization processes required by the LCD or payer.
Medical record must document reasonable and necessary basis for ESA therapy, including that Hb/HCT values, dose and route of administration, and that ESA use is appropriate for the individualized patient.

Key Coverage Criteria

Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
ESA therapy is indicated for anemia due to decreased erythropoietin production or relative erythropoietin resistance, e.g., anemia of chronic renal failure or end-stage renal disease (ESRD).
ESA therapy is indicated to maintain hematologic targets with typical goals of hematocrit 30.0-36.0% (hemoglobin 10.0-12.0 g/dL) and the medical record should document rationale for dose changes or values outside these ranges.
ESA therapy may be considered for other chronic conditions not specifically addressed by this policy when the patient demonstrates considerable transfusion dependence and anemia-related symptoms and documentation supports reasonable and necessary use.
Fluorescein angiography with interpretation is medically necessary as an adjunct to diagnosis of chorioretinal vascular abnormalities, especially choroidal neovascularization, noninfective vasculitis, and age-related macular degeneration (AMD).

20 Active Policies

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

J15

CGS-J15-L40386, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L39427, MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid Arthritis

J15

CGS-J15-L34246, Routine Foot Care and Debridement of Nails

J15

CGS-J15-L34175, Ophthalmic Angiography (Fluorescein and Indocyanine Green)

J15

CGS-J15-L34356, Erythropoiesis Stimulating Agents (ESA)

J15

CGS-J15-L34394, Visual Fields Testing

J15

CGS-J18-L34394, Visual Fields Testing

J18

CGS-J18-L34356, Erythropoiesis Stimulating Agents (ESA)

J18

CGS-J18-L34246, Routine Foot Care and Debridement of Nails

J18

CGS-J18-L34175, Ophthalmic Angiography (Fluorescein and Indocyanine Green)

J18

CGS-J18-L39427, MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid Arthritis

J18

CGS-J18-L40386, Erythropoiesis Stimulating Agents (ESA)

J18

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

J18

WPS-J5-L39481, MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid Arthritis

A55639, Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

WPS-J5-L34633, Erythropoiesis Stimulating Agents (ESAs)

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

A56795, Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)

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

`M06.811`, Other specified rheumatoid arthritis, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M06.811, Other specified rheumatoid arthritis, right shoulder

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M06.811`, Other specified rheumatoid arthritis, right shoulder