Does M35.5 require prior authorization?

No, M35.5 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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`M35.5`, Multifocal fibrosclerosis

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

Medical records must document the indication(s) supporting use of IVIG for each claim.
For indications where routine IVIG use is not indicated, the medical record must document prior interventions that were unsuccessful or reasons those interventions were not tolerated.
Documentation must support objective clinical response to IVIG for continued coverage.
Medical records must be made available to the Contractor upon request to substantiate coverage and payment.

Key Coverage Criteria

IVIG is covered only for indications specified as covered in the related Local Coverage Determination (LCD) and when medical necessity criteria in that LCD are met.
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.

12 Active Policies

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

WPS-J5-L34771, Immune Globulins

A57554, Billing and Coding: Immune Globulins

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

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M35.5, Multifocal fibrosclerosis