Does M05.061 require prior authorization?

No, M05.061 does not require prior authorization (low confidence). No active coverage policies found for this code.

`M05.061` — Felty's syndrome, right knee

ICD-10-CM

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Medical records must document the basis for each diagnosis and that diagnoses follow recognized standards (eg, American College of Rheumatology guidelines).
Medical records must include patient weight when needed to determine appropriate dosing.
Medical records must document evaluation for latent tuberculosis infection with a medical evaluation and TB test, and initiation of latent TB treatment prior to infliximab when indicated.
Medical records must document disease‑specific relevant symptoms and signs that are being treated and monitored to assess response to treatment.

Infliximab and its FDA‑approved biosimilars are covered when administered in accordance with the FDA‑approved label or recognized compendia for labeled and off‑label uses.
Covered for Crohn's disease when medical records document disease‑specific signs/symptoms (eg, abdominal pain, diarrhea, fistulae) and dosing per label or compendia; retreatment is covered if prior initial treatment produced reduction in clinical signs and symptoms.
Covered for rheumatoid arthritis when prescribed per label/compendia and medical record documents concomitant methotrexate use or a documented contraindication to methotrexate.
Covered for plaque psoriasis when documentation shows chronic, severe, extensive, or disabling disease (eg, percent BSA, PASI, or PDI) and the patient will have close physician follow‑up and monitoring.
Claims for pyoderma gangrenosum with coexisting inflammatory bowel disease are covered when the claim includes both primary and secondary ICD‑10‑CM diagnosis codes documenting pyoderma gangrenosum and IBD.
Anti-neoplastic (chemotherapy) agent CPT/HCPCS codes may be used to bill for administration of these drugs when given to treat non-oncologic (noncancer) diagnoses if the drug is medically necessary for the patient’s condition and consistent with the standard of medical practice.

A55639 — Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions

J05

L37205 — Chemotherapy Drugs and their Adjuncts

J05

A56795 — Billing and Coding: Erythropoiesis Stimulating Agents (ESAs)

J05

L34633 — Erythropoiesis Stimulating Agents (ESAs)

J05

Ask Verity about documentation requirements, denial risks, or coverage in your state.