Does I78.1 require prior authorization?

No, I78.1 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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`I78.1`, Nevus, non-neoplastic

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

Claims submitted without a valid ICD-10-CM diagnosis code will be returned as incomplete; the diagnosis code must best describe the patient's condition for the service performed.
The patient's medical record must contain documentation fully supporting medical necessity including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Medical record must document history and physical findings supporting a diagnosis of symptomatic varicose veins.
Medical record must document failure of an adequate trial of conservative treatment as described in the LCD.

Key Coverage Criteria

Interventional treatments are covered for symptomatic varicose veins of the lower extremity when the medical record documents history and physical findings supporting the diagnosis.
Coverage requires failure of an adequate trial of conservative treatment prior to interventional therapy as described in the LCD.
Coverage requires exclusion of other causes of limb edema, ulceration, and pain prior to treatment of varicose veins.
Coverage requires performance of appropriate diagnostic testing (e.g., duplex ultrasound) to confirm the presence and location of incompetent perforating veins when indicated.
Removal of benign or malignant skin lesions is addressed per the Local Coverage Determination L33445 and related billing/coding guidance.
Diagnosis code L82.0 (inflamed seborrheic keratosis) may be used when the medical record documents the patient's complaint or the physician's physical findings for the lesion.

10 Active Policies

A57482, Billing and Coding: Removal of Benign Skin Lesions

WPS-J5-L35498, Removal of Benign Skin Lesions

A52870, Billing and Coding: Treatment of Varicose Veins of the Lower Extremity

WPS-J8-L35498, Removal of Benign Skin Lesions

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I78.1, Nevus, non-neoplastic