Does M34.81 require prior authorization?

No, M34.81 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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`M34.81`, Systemic sclerosis with lung involvement

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 follow the complementary Local Coverage Determination (LCD L34430) and, when CPT 97000–97799 are used by PT/OT, must include documentation that the services meet the coverage and documentation requirements for physical or occupational therapy.
Billing and coding for pulmonary stress testing must follow Local Coverage Determination (LCD) L33444; consult LCD L33444 for specific medical necessity, coding, and billing criteria.
This article provides billing, coding, or other guidelines that complement LCD L33444 rather than standalone coverage criteria.
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

Therapeutic procedures whose principal aim is to treat a respiratory impairment must be billed using HCPCS codes G0237, G0238, or G0239.
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.
Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
Erythrocyte sedimentation rate (ESR) testing is covered only when reasonable and necessary as defined by Local Coverage Determination L34021.

20 Active Policies

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

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

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

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M34.81, Systemic sclerosis with lung involvement