Does M35.0B require prior authorization?

No, M35.0B 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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`M35.0B`, Sjogren syndrome with vasculitis

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.
Medical records must document the medical necessity of the serum magnesium test, including the signs, symptoms, and/or diagnosis that prompted the test.

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.

18 Active Policies

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

WPS-J5-L34594, Nerve Conduction Studies and Electromyography

WPS-J5-L37205, Chemotherapy Drugs and their Adjuncts

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M35.0B, Sjogren syndrome with vasculitis