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ICD-10-CM S31.805A, Open bite of unspecified buttock, initial encounter | No Prior Auth

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`S31.805A`, Open bite of unspecified buttock, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high 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.
IVIG may be indicated for pure red cell aplasia–related anemia.
Intramuscular immune globulin (gamma globulin) is indicated for post-exposure prophylaxis to hepatitis A.
IG is indicated for measles (rubeola) post-exposure prophylaxis in susceptible patients exposed less than 3 days prior to treatment.
IG is indicated for rubella prophylaxis in a woman in early pregnancy who is exposed and lacks immunity.
IVIG may be used for post-transfusion purpura and can be considered first-line for severely affected patients.

3 Active Policies

WPS-J5-L34771, Immune Globulins

J5

A57554, Billing and Coding: Immune Globulins

J5

WPS-J8-L34771, Immune Globulins

J8

Related Codes

90375(3 policies)90376(3 policies)90393(3 policies)90396(3 policies)96365(3 policies)96366(3 policies)96372(3 policies)90371(3 policies)

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For varicella prophylaxis, progress notes must document one of: personal history of leukemia/lymphoma, HIV infection, current immunosuppressive therapy, or a newborn exposure with documentation why newborn is at increased risk (e.g., maternal exposure within 5 days of delivery).

For tetanus immune serum, progress notes must identify that the wound is other than a clean minor wound and the date of injury, and must document that active tetanus immunization is unknown/uncertain, or <2 prior tetanus doses, or a ≥24-hour delay between injury and initiation of prophylaxis.