L44.0 — Pityriasis rubra pilaris
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- For transplant rejection and GVHD indications: documentation that disease is refractory to standard immunosuppressive drug treatment (clear record of prior and/or concurrent standard therapies, doses, dates, and documented lack of adequate response or contraindication to standard therapy).
- For GVHD after allogeneic bone marrow/stem cell transplant: documentation that disease is refractory to standard immunosuppressive drug treatment.
- Documentation of transplant status (e.g., appropriate Z94.xx codes) where relevant.
- No explicit 'Documentation Requirements' section appears in the provided text. Inferred documentation to support medical necessity based on the policy text includes:
Key Coverage Criteria
- ICD-10 codes covered if selection criteria are met (as listed in the policy):
- C84.00 - C84.09: Mycosis fungoides
- C84.10 - C84.19: Sezary's disease
- C84.A0 - C84.A9: Cutaneous T-cell lymphoma, unspecified
- D89.810 - D89.813: Graft-versus-host disease
- J42: Unspecified chronic bronchitis [only covered for rejection (bronchiolitis obliterans) in lung transplants] [not covered for bronchiolitis obliterans syndrome after allogeneic stem cell transplantation]
1 Active Policy
AETNA-CPB-0241 — Extracorporeal Photochemotherapy (Photopheresis)
Related Codes
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