Does 96365 require prior authorization?

No, 96365 does not require prior authorization (low confidence). No active coverage policies found for this code.

What is the Medicare reimbursement rate for 96365?

Medicare facility rate: $67.14. Non-facility rate: $67.14. Work RVU: 0.21.

HCPCS/CPT

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Work RVU

0.21

Facility

$67.14

Non-Facility

$67.14

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.

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.
Off-label IVIG use may be billed when supported by the applicable Local Coverage Determination (LCD) and by documentation of medical necessity; off-label is defined as not in Medicare-approved compendia or the FDA label.
IVIG may be used in bone marrow/stem cell transplantation when the recipient was CMV seropositive before transplantation, or after allogeneic transplantation for hematologic neoplasm when both donor and recipient were CMV seronegative.
IVIG may be used in solid organ transplantation when the donor was CMV seropositive and the recipient was CMV seronegative prior to transplantation.
IVIG may be used for recurrent severe infections when there is documented severe or absent IgG subclass deficiency or clinically significant functional humoral immunity deficiency (failure to produce specific antibodies) with a history of recurrent infections.
IVIG may be used for neuromuscular disorders when objective improvement is demonstrated and continued treatment is required, provided quantitative assessments are documented to monitor progress.

A57554 — Billing and Coding: Immune Globulins

J05

L34771 — Immune Globulins

J05

L39314 — Off-Label Use of Intravenous Immune Globulin (IVIG)

J06

L40181 — Off-Label Use of Intravenous Immune Globulin (IVIG)

J06

A59105 — Billing and Coding: Off-Label Use of Intravenous Immune Globulin (IVIG)

Ask Verity about documentation requirements, denial risks, or coverage in your state.