Does E11.51 require prior authorization?

No, E11.51 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`E11.51`, Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

The medical record must clearly document that the coverage indications, limitations, and medical necessity criteria in L37228 Wound Care have been met for any billed wound care item or service.
Documentation must support the specific CPT/HCPCS code(s) billed, including procedure details, depth and surface area for debridement codes, and rationale for the service.
When hydrotherapy (whirlpool) is billed with CPT 97597 or 97598, the record must state why hydrotherapy was necessary to remove devitalized/necrotic tissue and that a therapist's skill was required to perform the service.

Key Coverage Criteria

Traditional negative pressure wound therapy (NPWT) devices, units, and supplies are covered under the Durable Medical Equipment (DME) benefit when they meet DME LCD coverage criteria and medical necessity.
CPT codes 97597, 97598, and wound debridement codes 11042-11047 may be covered when the medical record documents medical necessity consistent with L37228 Wound Care criteria and Medicare reasonable-and-necessary requirements.
Foot care services are covered when the beneficiary has a listed systemic condition that justifies coverage per Medicare Benefit Policy Manual Pub.100-02, Ch.15, Section 290.4D.
For diagnosis codes designated by an asterisk, the patient must be under the active care of an M.D. or D.O., documented as having been seen for the complicating disease within the 6 months prior to service.
Claims asserting presumptive coverage must include a systemic-condition diagnosis from IOM 100-02 Ch.15 Section 290 Group 1 and a valid billing modifier Q7, Q8, or Q9.
Mycotic nail debridement is covered when mycotic nails are present in the context of a systemic disease with class findings and the appropriate Q modifier on the claim.

20 Active Policies

CGS-J15-L34246, Routine Foot Care and Debridement of Nails

J15

CGS-J15-L34045, Non-Invasive Vascular Studies

J15

CGS-J15-L38662, Implantable Continuous Glucose Monitors (I-CGM)

J15

CGS-J15-L34032, Debridement Services

J15

CGS-J15-L40199, MolDX: Biomarker Testing in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis

J15

CGS-J18-L34032, Debridement Services

J18

CGS-J18-L40199, MolDX: Biomarker Testing in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis

J18

CGS-J18-L38662, Implantable Continuous Glucose Monitors (I-CGM)

J18

CGS-J18-L34246, Routine Foot Care and Debridement of Nails

J18

CGS-J18-L34045, Non-Invasive Vascular Studies

J18

WPS-J5-L35490, Category III Codes

WPS-J5-L35761, Non-Invasive Peripheral Arterial Vascular Studies

WPS-J5-L38686, Implantable Continuous Glucose Monitors (I-CGM)

A56232, Billing and Coding: Foot Care

A55909, Billing and Coding: Wound Care

WPS-J5-L40272, MolDX: Biomarker Testing in Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis

A57593, Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies

WPS-J5-L37228, Wound Care

A58213, Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM)

NGS-J6-L38623, Implantable Continuous Glucose Monitors (I-CGM)

`E11.51`, Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

E11.51, Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

Prior Authorization

Documentation Required

Key Coverage Criteria

20 Active Policies

Related Codes

Have a follow-up question?

`E11.51`, Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene