B27.00 — Gammaherpesviral mononucleosis without complication
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims must be supported by medical record documentation of the patient’s diagnosis/clinical condition and justification that the selected drug, dose, and route of administration are appropriate and medically necessary for the non-oncologic indication.
- Billing must comply with Medicare rules and any applicable LCD prior authorization or documentation requirements; follow any specific forms or prior authorization processes required by the LCD or payer.
- Refer to Local Coverage Determination L35026 for clinical coverage criteria, medical necessity requirements, and any required prior authorization; this article complements that LCD with billing/coding guidance.
- The provided policy text does not specify required documentation (e.g., prior authorization forms, specific tests); documentation requirements for coverage (especially for off-label uses) should be confirmed with the A/B MAC.
Key Coverage Criteria
- Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.
- Monoclonal antibody agents and other biologic response modifiers may be administered and billed using chemotherapy administration codes for noncancer indications when the dose, route, and clinical use are appropriate and medically necessary.
- Rituximab is covered as a single agent for relapsed or refractory, low-grade or follicular, CD20-positive B-cell non-Hodgkin lymphoma (NHL).
- Rituximab is covered in previously untreated follicular, CD20-positive B-cell NHL in combination with first-line chemotherapy and, for patients achieving a complete or partial response, as single-agent maintenance therapy.
- Rituximab is covered as a single agent for non-progressing (including stable disease), low-grade, CD20-positive B-cell NHL after first-line cyclophosphamide, vincristine and prednisone (CVP) chemotherapy.
- Rituximab is covered in previously untreated diffuse large B-cell, CD20-positive NHL in combination with CHOP or other anthracycline-based chemotherapy regimens.
5 Active Policies
A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions
J05
L37205 — Chemotherapy Drugs and their Adjuncts
J05
ANTHEM-CG-SURG-113 — CG-SURG-113 Tonsillectomy with or without Adenoidectomy for Adults
A56380 — Billing and Coding: Rituximab
L35026 — Rituximab
Related Codes
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