Does L05.92 require prior authorization?

No, L05.92 does not require prior authorization (high confidence). Covered without prior authorization.

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`L05.92`, Pilonidal sinus without abscess

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Medical record must include relevant history, physical exam, and signs/symptoms that required the I&D procedure; diagnostic test results or the symptoms prompting tests must be recorded.
Pre-operative documentation must record size, location and appearance of the abscess/collection; the operative note must describe the procedure, equipment used, and approximate quantity (e.g., 1 cc, 5 ml) and quality (e.g., serous, bloody, frank pus) of material drained.
If multiple or repeated I&Ds are performed for the same anatomic area, records must explain reasons for recurrence and measures taken to prevent recurrence; photographic or operative documentation may be requested for patterns suggestive of abuse.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

Key Coverage Criteria

Incision and drainage (I&D) is covered when medical record documents an abscess, hematoma, seroma or other collection of the skin/subcutaneous/accessory structures requiring drainage with signs/symptoms that justify the procedure (e.g., evidence of infection, frank pus, severe pain, or failure of conservative measures).
For podiatry (specialty 48), CPT codes 10060, 10061 or 10160 are payable when billed with ICD-10-CM codes L02.611, L02.612 or L98.8 only.
CPT code 10140 is payable only when billed with the specified ICD-10-CM codes listed in the policy (multiple S- and L- codes for traumatic or specific skin conditions as enumerated).
Light and laser therapies are considered medically necessary for Port-wine stains/hemangiomata with pulsed dye laser therapy; for pilonidal sinus disease requiring hair regrowth control with laser hair removal when the patient has had or is undergoing surgical treatment; and for hypertrophic burn scars, fractional ablative laser fenestration (CO2/Er:YAG) is medically necessary if the scar causes functional impairment and the patient has failed at least one conservative treatment.
Chronic Stage III or IV pressure ulcer present for at least 30 days when a complete wound therapy program (see general measures and Stage III/IV specific measures) has been tried or considered and ruled out prior to application of NPWT.
Neuropathic ulcer (e.g., diabetic ulcer) present for at least 30 days when a complete wound therapy program (see general measures and neuropathic-specific measures) has been tried or considered and ruled out prior to application of NPWT.

7 Active Policies

NGS-J6-L33563, Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures

A56766, Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures

NGS-JK-L33563, Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures

UHC-POL-light-laser-therapy, Light and Laser Therapy

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L05.92, Pilonidal sinus without abscess