Does L02.611 require prior authorization?

No, L02.611 does not require prior authorization (high confidence). Covered without prior authorization.

`L02.611`, Cutaneous abscess of right foot

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

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.
If CPT 97597 or 97598 is billed by a therapist while the patient is under a Home Health benefit, coverage depends on inclusion in the Home Health plan of care; if billed by a physician or non-physician practitioner it is paid under Part B even if the beneficiary has an active Home Health plan.

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.

CGS-J15-L34200, Removal of Benign Skin Lesions

J15

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

J15

CGS-J18-L34200, Removal of Benign Skin Lesions

J18

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

J18

A56232

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