Does T50.995A require prior authorization?

No, T50.995A does not require prior authorization (high confidence). Covered without prior authorization.

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`T50.995A`, Adverse effect of other drugs, medicaments and biological substances, initial encounter

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical record documentation must demonstrate that the patient cannot tolerate oral bisphosphonates or that oral bisphosphonates are medically contraindicated (including documentation of severe esophagitis when applicable).
If inability to tolerate oral ibandronate is claimed, include appropriate intolerance/interaction codes (T50.995A-T50.995S, Y63.8, Z91.89, or Z92.89) in the documentation and claims as applicable.
For hypercalcemia of malignancy (E83.52), document the clinical rationale for ibandronate use and the specific related malignancy in the patient record.

Key Coverage Criteria

Intravenous ibandronate sodium is reasonable and necessary only for patients for whom bisphosphonate therapy (including oral ibandronate) is medically indicated and who cannot tolerate oral therapy or have a medical contraindication to oral bisphosphonates.
Use for osteoporosis (including senile or other osteoporosis) is covered when oral bisphosphonate therapy is indicated but cannot be used due to intolerance or contraindication.
Ibandronate sodium may be used for management of hypercalcemia of malignancy when the medical record documents the rationale for use and the related malignancy.
Ibandronate sodium may be used for osteoporosis that is a complication of transplant when the claim includes the related complication-of-transplant code and documentation of inability to tolerate oral bisphosphonates.
Paclitaxel administered intravenously is covered for antineoplastic (cancer) indications when used in accordance with the FDA-approved labeling.
Off-label uses of paclitaxel are covered when supported by recognized compendia (e.g., NCCN, AHFS, Clinical Pharmacology, Lexi-Drugs, Micromedex) and dosing/frequency follow those compendia.

20 Active Policies

CGS-J15-L40325, Allergy Diagnostic Testing

J15

CGS-J15-L37598, Cystatin C Measurement

J15

CGS-J15-L34063, RAST Type Tests

J15

CGS-J15-L34338, Transthoracic Echocardiography (TTE)

J15

CGS-J18-L40325, Allergy Diagnostic Testing

J18

CGS-J18-L34338, Transthoracic Echocardiography (TTE)

J18

CGS-J18-L34063, RAST Type Tests

J18

CGS-J18-L37598, Cystatin C Measurement

J18

WPS-J5-L36402, Allergy Testing

A57473, Billing and Coding: Allergy Testing

NGS-J6-L33591, RAST Type Tests

NGS-J6-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

A52450, Billing and Coding: Paclitaxel (e.g., Taxol/Abraxane )

NGS-J6-L40329, Allergy Diagnostic Testing

A56844, Billing and Coding: RAST Type Tests

A52421, Billing and Coding: Ibandronate Sodium

WPS-J8-L36402, Allergy Testing

FIRST_COAST-L33967, Vitamin B<sub>12</sub> Injections

FIRST_COAST-L37800, Allergen Immunotherapy

FIRST_COAST-L33261, Allergy Testing

`T50.995A`, Adverse effect of other drugs, medicaments and biological substances, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

T50.995A, Adverse effect of other drugs, medicaments and biological substances, initial encounter

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`T50.995A`, Adverse effect of other drugs, medicaments and biological substances, initial encounter