L13.0 — Dermatitis herpetiformis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service).
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the use of the selected ICD-10-CM code(s).
Key Coverage Criteria
- Esophagogastroduodenoscopy (EGD) is covered when it meets the reasonable and necessary requirements specified in Local Coverage Determination L33583.
- 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).
- Off-label use is allowable when first-line therapy produced an adverse reaction that absolutely contraindicates further use or causes non-transient side effects that impair functional capacity or activities of daily living, with the adverse event documented.
- Off-label use is allowable for refractory disease when documentation includes all first-line treatment(s) with dosing, frequency, duration, and documentation of response(s).
- Off-label use is allowable for disease relapse when documentation includes prior first-line treatment(s) with dosing, frequency, duration, duration of improvement on prior treatment(s), pertinent clinical history, exam findings, test results supporting relapse, and documentation of response to treatment at time of relapse.
- Re-treatment with rituximab or a biosimilar after initial treatment is permitted only when a positive response to prior rituximab is documented in the medical record.
6 Active Policies
A59101 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J06
A60186 — Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J06
L39297 — Off-label Use of Rituximab and Rituximab Biosimilars
J06
L40180 — Off-label Use of Rituximab and Rituximab Biosimilars
J06
Related Codes
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