Does I97.2 require prior authorization?

No, I97.2 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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`I97.2`, Postmastectomy lymphedema syndrome

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 diagnosis code must be included on every claim for the prosthesis or related item.
A treating practitioner's new order explaining the need for a different type of breast prosthesis must be created and retained in the supplier's files whenever the patient's medical condition changes; the order need not be submitted with the claim.
Documentation created by an orthotist or prosthetist is considered part of the patient's medical record and may support the treating practitioner's documentation for prosthetics per Social Security Act §1834(h)(5).
For items subject to Final Rule 1713, a prior face-to-face encounter and a Written Order Prior to Delivery (WOPD) are required and the WOPD must be in the supplier's files before delivery; absence of these documents results in denial.

Key Coverage Criteria

Custom fabricated breast prostheses, including molded-to-patient-model prostheses (HCPCS L8035), are covered when individually made for a specific patient and meet LCD reasonable and necessary criteria.
External breast prostheses are covered under the Prosthetic Devices benefit when the prosthesis is reasonable and necessary and meets the requirements of the related Local Coverage Determination (LCD).
Adhesive skin support (HCPCS A4280) is covered when used to attach an external breast prosthesis directly to the chest wall and when R&N requirements are met.
Occupational therapy is covered for patients with migraine (G43.xx) who require training to reduce pain during basic and instrumental activities of daily living, typically completed in 3–4 sessions.
Electrical stimulation (attended CPT 97032 or unattended HCPCS G0283) may be covered as part of a therapy plan of care to improve function when the nerve supply to the muscle is intact and atrophy is due to non-neurological disuse (e.g., post-casting, splinting, soft-tissue scarring).
Wheelchair management training (CPT 97542) is covered for patient and/or caregiver training in transfers and propulsion when documentation ties the training to attainable functional goals.

11 Active Policies

ANTHEM-MP-A050277, ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities

ANTHEM-CG-DME-06, Compression Devices for Lymphedema

CIGNA-CPG129, Electrodiagnostic Testing (EMG/NCV)

CIGNA-0354, Compression Devices

A52478, External Breast Prostheses - Policy Article

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I97.2, Postmastectomy lymphedema syndrome