Does D04.111 require prior authorization?

No, D04.111 does not require prior authorization (high confidence). Covered without prior authorization.

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`D04.111`, Carcinoma in situ of skin of right upper eyelid, including canthus

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

List the appropriate CPT code for the procedure and include any applicable modifiers; adhere to Medicare global surgery and CCI (correct coding initiative) rules for eyelid surgeries.
Submit physicians' services and diagnostic tests with a diagnosis code that supports medical necessity and code to the greatest level of specificity (full digit completeness).
Use the diagnosis code based on diagnostic test results as the primary diagnosis; if test results are normal or inconclusive, use the diagnosis code for the sign or symptom that prompted the test as the primary diagnosis.

Key Coverage Criteria

Blepharoplasty, blepharoptosis repair, or brow lift is covered when documented signs or symptoms of a functional abnormality of the upper eyelids are present as defined by the associated LCD (L34528).
Mohs micrographic surgery is covered when selected because the lesion's complexity (e.g., poorly defined borders, suspected deep invasion, recurrent lesion, prior radiation), size, or anatomic location requires maximal tissue conservation and other approaches (standard excision or destruction) are not medically reasonable or necessary.
Mohs surgery is considered covered when the surgeon performs both the surgical excision and the pathologic examination (surgeon acting in integrated surgical and pathology roles) as part of the Mohs technique.
Lab-developed tests for inherited cancer syndromes in patients with cancer as described in Local Coverage Determination (LCD) L39040 are the services addressed by this billing/coding guidance.
Blepharoplasty is covered for blepharochalasis when chronic recurrent eyelid edema has produced excess skin requiring functional repair.
Upper blepharoplasty is considered reconstructive and covered when excess upper eyelid tissue or abnormally low upper lid position produces functional visual complaints (e.g., interference with primary or downgaze reading or superior/lateral visual field loss).

20 Active Policies

CGS-J15-L40179, Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)

J15

CGS-J15-L40178, Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)

J15

CGS-J15-L33944, Blepharoplasty

J15

CGS-J15-L34393, Ocular Photography - External

J15

CGS-J15-L34037, Flow Cytometry

J15

CGS-J15-L34195, Mohs Micrographic Surgery

J15

CGS-J18-L34393, Ocular Photography - External

J18

CGS-J18-L34195, Mohs Micrographic Surgery

J18

CGS-J18-L34037, Flow Cytometry

J18

CGS-J18-L40178, Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)

J18

CGS-J18-L40179, Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)

J18

CGS-J18-L33944, Blepharoplasty

J18

WPS-J5-L40193, Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)

WPS-J5-L34528, Blepharoplasty, Blepharoptosis and Brow Lift

A56908, Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift

WPS-J5-L35494, Mohs Micrographic Surgery

WPS-J5-L39040, MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

WPS-J5-L40192, Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)

A57477, Billing and Coding: Mohs Micrographic Surgery

A58756, Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer

`D04.111`, Carcinoma in situ of skin of right upper eyelid, including canthus

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

D04.111, Carcinoma in situ of skin of right upper eyelid, including canthus

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`D04.111`, Carcinoma in situ of skin of right upper eyelid, including canthus