Does M35.00 require prior authorization?

No, M35.00 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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`M35.00`, Sjogren syndrome, 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

The submitted CPT/HCPCS code must accurately describe the ESR service performed.
Maintain the full medical record and make it available to the contractor upon request.
Every page of the record must be legible and include appropriate patient identification information (e.g., full name and dates of service).
The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.

Key Coverage Criteria

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.
Use ICD-10 codes T39.4X5A–T39.4X5S for ESR billing when the patient with rheumatoid arthritis is receiving antirheumatics such as gold salts for medication evaluation.
Use ICD-10 codes T45.1X5A–T45.1X5S for ESR billing when the patient with rheumatoid arthritis is receiving antineoplastic or immunosuppressive drugs such as methotrexate for medication evaluation.
Use ICD-10 codes T45.8X5A–T45.8X5S for ESR billing when the patient with rheumatoid arthritis is receiving other primarily systemic and hematological agents such as heavy metal antagonists for medication evaluation.
Use ICD-10 codes T50.6X5A–T50.6X5S for ESR billing when the patient with rheumatoid arthritis is receiving antidotes and chelating agents such as penicillamine for medication evaluation.

20 Active Policies

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

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

A59915, Billing and Coding: Pharmacogenomic Testing

NGS-J6-L39995, Pharmacogenomic Testing

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M35.00, Sjogren syndrome, unspecified