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ICD-10-CM L90.2 — Anetoderma of Jadassohn-Pellizzari | No Prior Auth

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`L90.2` — Anetoderma of Jadassohn-Pellizzari

ICD-10-CM

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Documentation Required

Medical records must document the indication(s) supporting use of IVIG for each claim.
For indications where routine IVIG use is not indicated, the medical record must document prior interventions that were unsuccessful or reasons those interventions were not tolerated.
Documentation must support objective clinical response to IVIG for continued coverage.
Medical records must be made available to the Contractor upon request to substantiate coverage and payment.

Key Coverage Criteria

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.
Intramuscular immune globulin (gamma globulin) is indicated for post-exposure prophylaxis to hepatitis A.
IG is indicated for measles (rubeola) post-exposure prophylaxis in susceptible patients exposed less than 3 days prior to treatment.
IG is indicated for rubella prophylaxis in a woman in early pregnancy who is exposed and lacks immunity.
IVIG may be used for post-transfusion purpura and can be considered first-line for severely affected patients.
Varicella-zoster immune globulin is indicated for passive immunization of immunosuppressed, exposed susceptible individuals when varicella zoster immunoglobulin is not available.

3 Active Policies

A57554 — Billing and Coding: Immune Globulins

J05

L34771 — Immune Globulins

J05

AETNA-CPB-0229 — Iontophoresis

Related Codes

90371(2 policies)90375(2 policies)90376(2 policies)90393(2 policies)90396(2 policies)

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For varicella prophylaxis, progress notes must document one of: personal history of leukemia/lymphoma, HIV infection, current immunosuppressive therapy, or a newborn exposure with documentation why newborn is at increased risk (e.g., maternal exposure within 5 days of delivery).

For tetanus immune serum, progress notes must identify that the wound is other than a clean minor wound and the date of injury, and must document that active tetanus immunization is unknown/uncertain, or <2 prior tetanus doses, or a ≥24-hour delay between injury and initiation of prophylaxis.

96365(2 policies)

96366(2 policies)

96372(2 policies)