E80.0 — Hereditary erythropoietic porphyria
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Supportive documentation evidencing the condition and treatment must be documented in the medical record and be available to the Contractor upon request.
- ICD-10-CM diagnosis codes supporting the medical necessity of the service must be submitted with each claim.
- High-utilization or repeat testing should include clinical justification in the record (for example, repeat testing due to unsatisfactory response to treatment) to support medical necessity.
- A complete medical and immunologic history and appropriate physical examination must be documented prior to diagnostic testing.
Key Coverage Criteria
- Allergy testing for inhalant allergens is covered when medically necessary; evaluation may include up to 90 prick-puncture tests followed by up to 40 intracutaneous tests if prick/puncture results are negative.
- Allergy testing for food sensitivity is covered when medically necessary and may require up to 40 percutaneous tests.
- Multitest intracutaneous testing of up to 60 tests may be appropriate in lieu of prick-puncture testing for selected patients (for example, young children, older adults, or needle-phobic individuals).
- Exceeding the stated testing parameters may be covered when preliminary testing failed and immunotherapy failed to control symptoms, provided documentation supports medical necessity.
- Photo testing and photopatch testing are covered for the evaluation of photosensitivity disorders and allergies related to light exposure.
- Allergy testing for immediate (IgE-mediated) and delayed (cell-mediated) hypersensitivity is covered when supported by scientifically valid peer-reviewed medical studies.
7 Active Policies
AETNA-CPB-0594 — Verteporfin (Visudyne) Photodynamic Therapy
UHC-POL-givlaari-givosiran — Givlaari (Givosiran)
UHC-POL-scenesse — Scenesse (Afamelanotide)
ANTHEM-CG-LAB-21 — CG-LAB-21 Serum Iron Testing
ANTHEM-CG-MED-68 — CG-MED-68 Therapeutic Apheresis
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.