N04.A — Nephrotic syndrome with C3 glomerulonephritis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Refer to Local Coverage Determination L35026 for clinical coverage criteria, medical necessity requirements, and any required prior authorization; this article complements that LCD with billing/coding guidance.
- The provided policy text does not specify required documentation (e.g., prior authorization forms, specific tests); documentation requirements for coverage (especially for off-label uses) should be confirmed with the A/B MAC.
Key Coverage Criteria
- Rituximab is covered as a single agent for relapsed or refractory, low-grade or follicular, CD20-positive B-cell non-Hodgkin lymphoma (NHL).
- Rituximab is covered in previously untreated follicular, CD20-positive B-cell NHL in combination with first-line chemotherapy and, for patients achieving a complete or partial response, as single-agent maintenance therapy.
- Rituximab is covered as a single agent for non-progressing (including stable disease), low-grade, CD20-positive B-cell NHL after first-line cyclophosphamide, vincristine and prednisone (CVP) chemotherapy.
- Rituximab is covered in previously untreated diffuse large B-cell, CD20-positive NHL in combination with CHOP or other anthracycline-based chemotherapy regimens.
- Rituximab in combination with fludarabine and cyclophosphamide (FC) is covered for the treatment of previously untreated and previously treated CD20-positive chronic lymphocytic leukemia (CLL).
- Rituximab with methotrexate is covered for adult patients (age >=18) with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response to one or more tumor necrosis factor (TNF) antagonist therapies.
3 Active Policies
ANTHEM-CG-MED-68 — CG-MED-68 Therapeutic Apheresis
A56380 — Billing and Coding: Rituximab
L35026 — Rituximab
Related Codes
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