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Billing for Off-Label or Unproven Indication

Last modified: June 16, 2020

When submitting claims for specialty drugs, please remember to include supported ICD-10-CM diagnosis code(s), as outlined in our Medical Benefit Drug Policy Guidelines. This can save time, as claims containing HCPCS© codes for drugs without the approved ICD-10-CM diagnosis may result in additional reviews or other actions. In some cases, a representative from Optum will contact you to review the claim.

Keep in mind, the correct use of an ICD-10-CM code listed in the policy does not guarantee coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the policy.

You can find more information about our policies and guidelines here