L10.9 — Pemphigus, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation should demonstrate the presence of at least one qualifying indication (e.g., records documenting failure of conventional therapy, documentation of contraindication, or evidence of rapidly progressive disease and rationale for short-term IVIg use with conventional therapy).
- Be aware that local contractors may require additional local documentation or definitions (e.g., local coverage determination/criteria), and providers should follow Noridian or applicable LCD requirements.
- 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.
- Claims missing required NOC narrative information or with incorrect unit reporting will be rejected as unprocessable and may show remark code M123.
Key Coverage Criteria
- IVIg is covered when the patient has failed conventional therapy for the treated condition.
- IVIg is covered when conventional therapy is contraindicated for the patient.
- IVIg is covered for rapidly progressive disease when a clinical response cannot be achieved quickly enough using conventional agents and IVIg is used only short-term alongside conventional treatment until that therapy takes effect.
- Billing and coding guidance in this article applies when immune globulin use meets the reasonable and necessary coverage criteria established in LCD L35093.
- 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.
- Coverage requires documentation that the immune globulin therapy is reasonable and necessary in accordance with LCD L34007 and applicable NCDs.
20 Active Policies
A57554 — Billing and Coding: Immune Globulins
J05
L34771 — Immune Globulins
J05
L40181 — Off-Label Use of Intravenous Immune Globulin (IVIG)
J06
L39314 — Off-Label Use of Intravenous Immune Globulin (IVIG)
J06
L39297 — Off-label Use of Rituximab and Rituximab Biosimilars
Related Codes
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