96450
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.53
Facility
$66.47
Non-Facility
$160.99
Documentation Required
- No explicit documentation requirements provided in this document (no 'Documentation' section).
- Inferred reasonable documentation to support rituximab use (based on the clinical contexts and statements in the text):
- - Confirmed diagnosis related to the intended indication (e.g., antibody testing: anti-NMDAR, LGI1, VGKC-complex, ANCA, anti-SRP, anti-MAG, anti-retina antibodies; biopsy/pathology where applicable).
- - Evidence of disease severity and organ involvement (e.g., modified Rankin Scale (mRS) for encephalitis, INCAT sensory score or disability scales for neuropathy, ISS for anti-MAG neuropathy, scleritis grading scales).
Key Coverage Criteria
- Siliq (brodalumab): Plaque psoriasis
- Simponi (golimumab): Ankylosing spondylitis
- Simponi (golimumab): Psoriatic arthritis
- Simponi (golimumab): Rheumatoid arthritis
- Simponi (golimumab): Ulcerative colitis
- FDA-labeled indications (from Appendix table): Microscopic polyangiitis
2 Active Policies
AETNA-CPB-0290 — Scalp Cooling (Hypothermia) to Prevent Hair Loss During Chemotherapy
AETNA-CPB-0314 — Rituximab
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.