Does D69.42 require prior authorization?

No, D69.42 does not require prior authorization (high confidence). Code is covered without prior authorization.

`D69.42` — Congenital and hereditary thrombocytopenia purpura

ICD-10-CM

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.
The submitted medical record must support the selected ICD-10-CM code(s), and the submitted CPT/HCPCS code must accurately describe the service performed.
The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.

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.
For tests that currently lack specific CPT codes (functional intracellular analysis and total antioxidant function), bill using CPT 84999 and add a note identifying which test was performed in the Remarks area for Part A claims and the Narrative area for Part B claims.
Coverage and reasonable/necessary determinations for assays for vitamins and metabolic function are governed by LCD L34914 and claims must meet that LCD's requirements to be covered.
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 use of rituximab or rituximab biosimilars is allowable when the patient has documented lack of efficacy of prior treatments, including dosing, frequency, duration, and documentation of response(s).

L34771 — Immune Globulins

J05

A57554 — Billing and Coding: Immune Globulins

J05

A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

J05

L37205 — Chemotherapy Drugs and their Adjuncts

J05

L39297 — Off-label Use of Rituximab and Rituximab Biosimilars

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