Does M35.09 require prior authorization?

No, M35.09 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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`M35.09`, Sjogren syndrome with other organ 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.
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.

20 Active Policies

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

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

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

A58893, 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

WPS-J8-L37205, Chemotherapy Drugs and their Adjuncts

A57657, Billing and Coding: Sedimentation Rate, Erythrocyte

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

FIRST_COAST-L34021, Sedimentation Rate, Erythrocyte

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

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

AETNA-CPB-0608, Salivary Tests

AMBETTER-CP.VP.06, Medically Necessary Optical Hardware

AETNA-CPB-0113, Botulinum Toxin

AETNA-CPB-0302, Xerostomia: Selected Treatments

AETNA-CPB-0344, Optic Nerve and Retinal Imaging Methods

AETNA-CPB-0606, Hematopoietic Cell Transplantation for Autoimmune Diseases and Miscellaneous Indications

ANTHEM-CG-LAB-29, Gamma Glutamyl Transferase Testing

A56380, Billing and Coding: Rituximab

`M35.09`, Sjogren syndrome with other organ involvement

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

M35.09, Sjogren syndrome with other organ involvement

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`M35.09`, Sjogren syndrome with other organ involvement