Does M33.12 require prior authorization?

No, M33.12 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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`M33.12`, Other dermatomyositis with myopathy

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 clinical history from the referral source indicating the need for testing must be available in the medical record and retrievable for review.
If an E/M service is billed as separate and identifiable, medical record must document medical necessity and the E/M CPT code must be billed with modifier 25.

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.
Electrodiagnostic testing (EMG and/or nerve conduction studies) is indicated for evaluation of suspected carpal tunnel syndrome.
EMG and/or nerve conduction studies are indicated for evaluation of suspected radiculopathy.
EMG and/or nerve conduction studies are indicated for evaluation of suspected mononeuropathy (single-nerve entrapment or injury).
EMG and/or nerve conduction studies are indicated for evaluation of suspected polyneuropathy or mononeuropathy multiplex.

20 Active Policies

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

J15

CGS-J15-L35891, Intravenous Immune Globulin

J15

CGS-J15-L35897, Nerve Conduction Studies and Electromyography

J15

CGS-J18-L35891, Intravenous Immune Globulin

J18

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M33.12, Other dermatomyositis with myopathy