L95.0 — Livedoid vasculitis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Claims should reference and be supported by LCD L34580 and follow the billing/coding guidelines in this article; specific documentation requirements (e.g., medical records, prior authorization) are those detailed in LCD L34580.
- Evidence of blood levels demonstrating significant gammaglobulin deficiency prior to initial treatment should be documented where appropriate.
- Medical record must document medical necessity to initiate and continue IVIG, including history and physical and office/progress notes.
- Test results with written interpretation must be in the record, including relevant diagnostic testing (e.g., NCS, EMG, CSF, serum immunoprotein, muscle/nerve biopsy) as appropriate to the treated condition.
Key Coverage Criteria
- Billing and coding for intravenous immunoglobulin (IVIG) should follow the Local Coverage Determination (LCD) L34580 and the billing/coding guidelines in this article as a complement to that LCD.
- Off-label IVIG use may be billed when supported by the applicable Local Coverage Determination (LCD) and by documentation of medical necessity; off-label is defined as not in Medicare-approved compendia or the FDA label.
- IVIG may be used in bone marrow/stem cell transplantation when the recipient was CMV seropositive before transplantation, or after allogeneic transplantation for hematologic neoplasm when both donor and recipient were CMV seronegative.
- IVIG may be used in solid organ transplantation when the donor was CMV seropositive and the recipient was CMV seronegative prior to transplantation.
- IVIG may be used for recurrent severe infections when there is documented severe or absent IgG subclass deficiency or clinically significant functional humoral immunity deficiency (failure to produce specific antibodies) with a history of recurrent infections.
- IVIG may be used for neuromuscular disorders when objective improvement is demonstrated and continued treatment is required, provided quantitative assessments are documented to monitor progress.
6 Active Policies
A59105 — Billing and Coding: Off-Label Use of Intravenous Immune Globulin (IVIG)
J06
A60187 — Billing and Coding: Off-Label Use of Intravenous Immune Globulin (IVIG)
J06
L39314 — Off-Label Use of Intravenous Immune Globulin (IVIG)
J06
L40181 — Off-Label Use of Intravenous Immune Globulin (IVIG)
J06
Related Codes
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