Does M35.08 require prior authorization?

No, M35.08 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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`M35.08`, Sjogren syndrome with gastrointestinal 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 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.
Refer to Local Coverage Determination L35026 for clinical coverage criteria, medical necessity requirements, and any required prior authorization; this article complements that LCD with billing/coding guidance.

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.

17 Active Policies

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

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

A57478, Billing and Coding: Nerve Conduction Studies and Electromyography

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

WPS-J5-L34594, Nerve Conduction Studies and Electromyography

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-L34594, Nerve Conduction Studies and Electromyography

FIRST_COAST-L34021, Sedimentation Rate, Erythrocyte

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

A57657, Billing and Coding: Sedimentation Rate, Erythrocyte

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A57189, Billing and Coding: Serum Magnesium

A56421, Billing and Coding: CT of the Abdomen and Pelvis

A56380, Billing and Coding: Rituximab

`M35.08`, Sjogren syndrome with gastrointestinal involvement

Prior Authorization

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

M35.08, Sjogren syndrome with gastrointestinal involvement

Prior Authorization

Documentation Required

Key Coverage Criteria

17 Active Policies

Related Codes

Have a follow-up question?

`M35.08`, Sjogren syndrome with gastrointestinal involvement