Does M33.20 require prior authorization?

No, M33.20 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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`M33.20`, Polymyositis, organ involvement unspecified

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.
All documentation must be maintained in the patient medical record and made available to the contractor upon request, with every page legible and including patient identification (complete name, dates of service).

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.
25-hydroxy vitamin D testing (including fractions, if performed) is covered when deemed reasonable and necessary per Local Coverage Determination L33771.
IVIG is covered only for indications specified as covered in the related Local Coverage Determination (LCD) and when medical necessity criteria in that LCD are met.
Erythrocyte sedimentation rate (ESR) testing is covered only when reasonable and necessary as defined by Local Coverage Determination L34021.
ESR performed for rheumatoid arthritis patients to assess the need for medication adjustments should be billed with a diagnosis code that reflects the specific antirheumatic medication the patient is receiving.

20 Active Policies

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

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

WPS-J5-L34771, Immune Globulins

A57554, Billing and Coding: Immune Globulins

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

A57668, Billing and Coding: Nerve Conduction Studies and Electromyography

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

NGS-J6-L39314, Off-Label Use of Intravenous Immune Globulin (IVIG)

NGS-J6-L35098, Nerve Conduction Studies and Electromyography

A59105, Billing and Coding: Off-Label Use of Intravenous Immune Globulin (IVIG)

A59101, Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

WPS-J8-L37205, Chemotherapy Drugs and their Adjuncts

WPS-J8-L34771, Immune Globulins

FIRST_COAST-L33771, Vitamin D; 25 hydroxy, includes fraction(s), if performed

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

A56841, Billing and Coding: Vitamin D; 25 hydroxy, includes fraction(s), if performed

A57657, Billing and Coding: Sedimentation Rate, Erythrocyte

FIRST_COAST-L34021, Sedimentation Rate, Erythrocyte

NOVITAS-JH-L34914, Assays for Vitamins and Metabolic Function

`M33.20`, Polymyositis, organ involvement unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M33.20, Polymyositis, organ involvement unspecified

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M33.20`, Polymyositis, organ involvement unspecified