Does B42.1 require prior authorization?

No, B42.1 does not require prior authorization (high confidence). Covered without prior authorization.

`B42.1`, Lymphocutaneous sporotrichosis

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

All documentation must be maintained in the patient's medical record, be legible, include patient identification and dates of service, and be made available to the contractor upon request.
The record must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
The provider must document the affected nail(s), clinical evidence of mycosis, and the manner and extent to which the nail(s) were debrided.

Nail debridement is covered only when the service meets all indications and limitations specified in LCD L33922 and applicable CMS medical necessity and payment rules.
Nail debridement for symptomatic mycotic nails is covered when there is documented clinical evidence of mycosis and qualifying symptoms for toenail debridement.
Clinical evidence of mycotic (fungal) infection of the nail demonstrated by discoloration, onycholysis, subungual debris, thickening, or secondary skin infection.
For mycotic toenails, debridement is covered only when the medical record documents either: (a) an ambulatory patient with marked limitation of ambulation, pain, or secondary infection from thickening/dystrophy of the infected toenail plate(s); or (b) a non-ambulatory patient with pain or secondary infection from thickening/dystrophy of the infected toenail plate(s).
Appropriate antifungal treatment must be used for nail debridement to be considered medically necessary and reimbursable unless a contraindication to antifungal therapy is documented in the medical record.
An underlying systemic condition is not required for coverage of mycotic nail care.

FIRST_COAST-L33922, Nail Debridement

A57672, Billing and Coding: Nail Debridement

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