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ICD-10-CM N04.A, Nephrotic syndrome with C3 glomerulonephritis | No Prior Auth

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`N04.A`, Nephrotic syndrome with C3 glomerulonephritis

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

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

Renal transplant recipients who are ABO compatible who are experiencing antibody mediated rejection (AMR) or require desensitization (living donor)
Wilsonâs disease - fulminant
Renal transplant recipients who are ABO incompatible and require desensitization (living donor)
Plasmapheresis or plasma exchange is consideredmedically necessaryfor any of the following conditions listed in alphabetical order below:Acute inflammatory demyelinating polyradiculoneuropathy / Guillain-Barre syndromeAnti-glomerular basement membrane disease (Goodpasture's syndrome) when the individual is dialysis-independent or there is evidence of diffuse alveolar hemorrhage (DAH)Atypical hemolytic uremic syndrome (aHUS) with Factor H autoantibodies or complement gene mutationAutoimmune hemol [...]
Acute inflammatory demyelinating polyradiculoneuropathy / Guillain-Barre syndrome
Anti-glomerular basement membrane disease (Goodpasture's syndrome) when the individual is dialysis-independent or there is evidence of diffuse alveolar hemorrhage (DAH)

2 Active Policies

ANTHEM-CG-MED-68, Therapeutic Apheresis

A56380, Billing and Coding: Rituximab

Related Codes

D59.12(2 policies)G04.81(2 policies)C88.01(2 policies)D59.0(2 policies)D89.1(2 policies)D89.89(2 policies)C88.00(2 policies)G35.A(2 policies)

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