B37.0 — Candidal stomatitis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- No explicit documentation requirements are stated in this Clinical Policy Bulletin.
- Medical records documenting absence of contraindicated prior toxicities for retreatment (e.g., no prior sustained VT ≥5 beats, uncontrolled arrhythmias, prolonged intubation/dialysis, prolonged coma/toxic psychosis, bowel ischemia/perforation, GI bleeding requiring surgery, etc.).
- Monitoring and adverse event documentation (evidence of monitoring for capillary leak syndrome, infections, neurologic status, hemodynamics) as part of treatment records.
- Any other clinical notes, imaging, or lab data supporting clinical indication (tumor response assessments, pathology, staging) as relevant to the indication.
Key Coverage Criteria
- None specified. Aetna considers the analysis of volatile organic compounds experimental and investigational for the indications listed below (see Limitations).
- Cutaneous melanoma — as high-dose single-agent subsequent therapy for metastatic or unresectable disease
- Metastatic melanoma (FDA‑approved indication for treatment of adults with metastatic melanoma)
- Metastatic renal cell carcinoma with clear cell histology (FDA‑approved indication for treatment of adults with metastatic renal cell carcinoma)
- Chronic graft‑versus‑host disease (GVHD) — for treatment as additional therapy in conjunction with systemic corticosteroids following no response to first‑line therapy options
- Neuroblastoma — for treatment of neuroblastoma (see CPB 0895 - Dinutuximab (Unituxin))
5 Active Policies
AETNA-CPB-0024 — Aldesleukin (Proleukin)
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
AETNA-CPB-0717 — Analysis of Volatile Organic Compounds
ANTHEM-CG-MED-73 — CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
ANTHEM-CG-LAB-29 — CG-LAB-29 Gamma Glutamyl Transferase Testing
Related Codes
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