L14, Bullous disorders in diseases classified elsewhere
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must include the ordering provider's assessment related to the complaint, relevant medical history, results of pertinent tests/procedures, and signed and dated office visit or operative reports.
- Required documentation of medical necessity includes history and physical, a supporting physician rationale current within the last 12 months, and physician orders not more than 30 days old specifying dose, frequency, administration route and duration, with office/progress notes documenting necessity for initiation and continuation.
- An accurate weight in kilograms must be documented prior to each infusion because dosing is mg/kg.
- Medication administration records and documentation of the patient's response to prior infusions must accompany each order for ongoing therapy.
Key Coverage Criteria
- IVIG is covered for patients with common variable immunodeficiency (CVID) when initial presenting IgG levels, evidence of Pneumovax vaccination, and pre- and post-vaccine pneumococcal antibody titers demonstrate inability to produce an antibody response to protein or carbohydrate antigens, and documentation includes dual diagnoses and a statement of lack of response to protein antigen.
- IVIG is covered for patients with HIV disease and immune thrombocytopenic purpura (ITP) when the medical record documents a platelet count less than 30,000 and active bleeding supported by laboratory results.
- IVIG is covered for immunodeficient individuals with recurrent or chronic bacterial sinusitis when the record documents findings diagnostic of or highly suggestive of bacterial sinus infection (for example fever, unilateral purulent nasal discharge, unilateral facial pain) and documents prolonged and/or recurrent antibiotic therapy.
- IVIG is covered for stiff-man syndrome when the patient is under the care of a physician competent in diagnosis, meets the defined diagnostic criteria, has failed conservative therapy (e.g., benzodiazepines), and documentation shows objective response after initial treatment for continued coverage.
- IVIG is covered when the treating physician documents medical necessity for initiation or continuation, including history and physical, a current supporting physician rationale (within 12 months), and physician orders (<=30 days old) specifying dose, frequency, administration route and duration with office/progress notes documenting response.
- 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.
7 Active Policies
CGS-L35891, Intravenous Immune Globulin
J15
A57554, Billing and Coding: Immune Globulins
J5
A59101, Billing and Coding: Off-label Use of Rituximab and Rituximab Biosimilars
J6
WPS-L34771, Immune Globulins
J8
NGS-L40180, Off-label Use of Rituximab and Rituximab Biosimilars
Related Codes
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