L90.6 — Striae atrophicae
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.
4 Active Policies
A57554 — Billing and Coding: Immune Globulins
J05
L34771 — Immune Globulins
J05
AETNA-CPB-0559 — Pulsed Dye Laser Treatment
AETNA-CPB-0735 — Pulsed Radiofrequency
Related Codes
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