Does M31.19 require prior authorization?

No, M31.19 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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`M31.19`, Other thrombotic microangiopathy

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.
A permanent record of the studies performed and the interpretation must be maintained in the medical record.
The report must describe the studies performed and document any contrast media and/or radiopharmaceuticals used.

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.
Non-invasive cerebrovascular/vascular studies are covered when the study results will be used to directly inform or change the clinical management of the patient.
Re-evaluation of carotid artery stenosis is covered for patients with diameter reduction >50% who are symptomatic and these patients are normally followed on an annual basis.
Re-evaluation of carotid artery stenosis is covered for patients with diameter reduction >60% who are asymptomatic and these patients are normally followed on an annual basis.
Repeat duplex ultrasound scans are covered at any time for patients who become symptomatic of carotid disease, without regard to scheduled surveillance intervals.

20 Active Policies

CGS-J15-L38920, Off-label Use of Rituximab and Rituximab Biosimilars

J15

CGS-J15-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J15

CGS-J18-L39038, MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J18

CGS-J18-L38920, Off-label Use of Rituximab and Rituximab Biosimilars

J18

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M31.19, Other thrombotic microangiopathy