D81.5 — Purine nucleoside phosphorylase [PNP] deficiency
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A face-to-face encounter and a Written Order Prior To Delivery (WOPD) are required for the Final Rule 1713 specified HCPCS codes; if delivery occurs before WOPD the item is not payable even if WOPD is later obtained.
- For continuous subcutaneous insulin pump coverage, document glucose self-testing averaging >=4 times per day or document use of a CGM device in the beneficiary's medical record to meet the testing requirement.
- For parenteral inotropic drugs the prescribing practitioner must verify that an initial evaluation was performed by a cardiologist trained in advanced heart failure, retain documentation of that evaluation, and provide a copy of the initial evaluation and the prescription to the DMEPOS supplier.
- For epoprostenol or treprostinil, suppliers should submit signed and dated practitioner documentation including beneficiary diagnosis, current symptoms caused by pulmonary hypertension, date and results of pulmonary artery pressure, statement that PH is not secondary to pulmonary venous hypertension or a respiratory disorder, and statement about prior trial (or reason for no trial) of oral calcium channel blockers.
Key Coverage Criteria
- External infusion pumps are covered as Durable Medical Equipment (DME) when the device meets Medicare DME benefit rules and the reasonable and necessary (R&N) requirements in the related Local Coverage Determination (LCD).
- External infusion pumps for administration of continuous subcutaneous insulin are covered when the beneficiary documents glucose self-testing averaging at least 4 times per day or documents use of a continuous glucose monitor (CGM).
- Parenteral inotropic drug therapy (for advanced heart failure) is covered when reasonable and necessary criteria are met and an initial evaluation was performed by a cardiologist trained in advanced heart failure (per LCD requirements).
- IVIG is covered when the patient has a diagnosis of primary immunodeficiency disease documented on the claim.
- IVIG is covered when the IVIG product is administered in the patient's home.
- IVIG is covered when the treating practitioner documents that home administration is medically appropriate for the patient.
20 Active Policies
L34771 — Immune Globulins
J05
L39044 — MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
A58761 — Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing
J05
A57554 — Billing and Coding: Immune Globulins
J05
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