B08.4 — Enteroviral vesicular stomatitis with exanthem
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical evidence supporting diagnosis (e.g., laboratory or diagnostic test results, such as pathogen identification by appropriate testing) and medical records showing clinical severity and rationale for inhaled ribavirin therapy.
- Records demonstrating treatment regimen and administration details as applicable (the CPB cites recommended dosing regimen: 20 mg/mL Virazole in SPAG-2 unit with continuous aerosol administration 12-18 hours/day for 3-7 days as recommended dosing information from Virazole prescribing information).
- No explicit 'Documentation Requirements' section or specific documentation checklist is provided in this CPB.
- Implied/expected documentation (not explicitly required by policy text): documentation supporting the covered diagnosis (e.g., clinical diagnosis of RSV, viral hemorrhagic fever, Rift Valley fever, Hantaan infection) and that patient meets the described population (e.g., immunosuppressed or high-risk child/adult; hospitalized infant/young child with severe LRTI due to RSV).
Key Coverage Criteria
- Ribavirin (Virazole) inhalation medically necessary for the treatment of: Respiratory syncytial virus (RSV) infection in immunosuppressed and high risk children and adults;
- Ribavirin (Virazole) inhalation medically necessary for the treatment of: Viral hemorrhagic fever (Crimean-Congo, Ebola, Lassa, and Marburg);
- Ribavirin (Virazole) inhalation medically necessary for the treatment of: Rift valley fever and Hantaan, a hanta virus.
- FDA-Approved indication: Virazole (ribavirin for inhalation solution, USP) is indicated for the treatment of hospitalized infants and young children with severe lower respiratory tract infections due to RSV.
- Covered ICD-10 codes (if selection criteria met): A92.0 - A92.9 (Other mosquito-borne fever [e.g., Rift valley])
- Covered ICD-10 codes (if selection criteria met): A96.2
1 Active Policy
AETNA-CPB-0155 — Ribavirin (Virazole) Inhalation
Related Codes
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